DEFINITIONS:
• ILI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F) and
– cough
– with onset within last 10 days
• SARI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F),
– cough
– with onset within the last 10 days and
– requiring hospitalization
• Respiratory failure
– Represents the failure of the lung to maintain adequate gas exchange
– Characterized by ABG abnormalities: PaO2< 60 mmHg with or without hypercarbia PaCO2> 46 mmHg (with drop in pH<7.30)
COVID-19 (Coronavirus Disease 2019) is an infectious disease caused by the recently found virus known as SARS-CoV-2 (or coronavirus). Before the outbreak originated in Wuhan, China on December 2019, there was no information about this virus. Case Definition (India), Symptoms, Statistics, Preventive Measures, Management
COVID-19 (Coronavirus Disease 2019) is an infectious disease caused by the recently found virus known as SARS-CoV-2 (or coronavirus). Before the outbreak originated in Wuhan, China on December 2019, there was no information about this virus. Case Definition (India), Symptoms, Statistics, Preventive Measures, Management
In COVID-19 any antiviral is more effective when used early in first week of illness.
What should not be used in covid-19 is also discussed in presentation.
PERIOPERATIVE MANAGEMENT OF COVID 19 SUSPECT/ CONFIRMED PATIENTBhagwatiPrasad18
These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time.
Watch this presentation in laptop/ pc as slideshow for beautiful animations.
In COVID-19 any antiviral is more effective when used early in first week of illness.
What should not be used in covid-19 is also discussed in presentation.
PERIOPERATIVE MANAGEMENT OF COVID 19 SUSPECT/ CONFIRMED PATIENTBhagwatiPrasad18
These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time.
Watch this presentation in laptop/ pc as slideshow for beautiful animations.
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
1. LATEST GUIDELINES COVID 2020
DEFINITIONS:
• ILI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F) and
– cough
– with onset within last 10 days
• SARI is defined as one with acute respiratory infection
– with fever ≥ 380 C (100.40F),
– cough
– with onset within the last 10 days and
– requiring hospitalization
• Respiratory failure
– Represents the failure of the lung to maintain adequate gas exchange
– Characterized by ABG abnormalities: PaO2< 60 mmHg with or without hypercarbia PaCO2> 46 mmHg (with drop in pH<7.30)
COVID 19 RT-PCR POSITIVE PATIENT
1. Management of any COVID 19 patient mandates the Health Care Personnel (HCP) to bein full Personal Protection Equipment(PPE).
2. Patient is Categorized in to three groups:
CATEGORY Type of patients who are provided treatment and care
Group A Asymptomatic/Patients with mild symptoms
RR<24/m & SpO2>94% in room air
Group B Symptomatic patient with mild to moderate Pneumonia with no signs of
severe disease
RR: 24-30/m (or) SPO2: 90%-94% at Room Air
Group C Symptomatic patient with Severe Pneumonia with
RR > 30/min (or) SPO2 < 90% at Room Air (or) less than 94% with
oxygen, ARDS, Septic Shock
CLINICAL CATEGORIES
Clinical
category
Description Parameters
Asymptomatic No Symptoms
SpO2: ≥94% in room air
RR: ≤ 24/m
No evidence of hypoxemia or breathlessness
Mild
Patients with
uncomplicated upper
respiratory tract
infection.
SpO2: ≥94% in room air
RR: ≤ 24/m
No evidence of hypoxemia or breathlessness
Moderate
Pneumonia with no
signs of severe
disease
Sp02: 94%-90% in room air
RR: 24-30/m
Severe Severe Pneumonia SpO2: < 90% room air
RR: >30/m
Critical
Acute Respiratory
Distress Syndrome
(ARDS)
Onset: new or worsening respiratory symptoms
within one week of known clinical insult.
Chest imaging (Chest X ray and portable bed side
lung ultrasound): bilateral opacities, not fully
explained by effusions, lobar or lung collapse, or
nodules.
Origin of Pulmonary infiltrates: respiratory failure
not fully explained by cardiac failure or fluid
overload. Need objective assessment (e.g.
echocardiography) to exclude hydrostatic cause of
infiltrates/ oedema if no risk factor present.
Oxygenation impairment in adults:
Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg
(with PEEP or CPAP ≥5 cm H2O)
Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200
mmHg with PEEP
≥5 cm H2O)
Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP
≥5 cm H2O)
When PaO2 is not available, SpO2/FiO2 ≤315
suggests ARDS (including in non- ventilated
patients)
2. Critical Septic Shock
Adults: persisting hypotension despite volume
resuscitation, requiring vasopressors to maintain
MAP ≥65 mmHg and serum lactate level > 2 mmol/L
INVESTIGATIONS
Timing Mild Moderate Severe/Critical
At
admission
CBC
RBS
ECG
HbA1C (if Diabetic)
D-Dimer
(If starting on Tab
Favipiravir)
RFT
S.Electrolyte
S. Uric Acid
• Complete Blood Count
(with N/L RATIO)
• LFT, RFT, RBS
• S.Electrolytes
• 12 lead ECG
• CHEST X Ray –PA view
• CRP, D-DIMER
• S. FERRITIN, S.LDH
• PROCALCITONIN
• TROP – I & T
• PT/INR
• ABG
• CT Thorax (if Available)
• Blood culture (if total
count is high)
• IL – 6
• S. Cortisol
• 2D
ECHOCARDIOGRAP
HY
• COVID Antibody
IgM/IgGTests
•Complete Blood Count
(with N/L RATIO)
•LFT, RFT, RBS
•S. Electrolytes
•12 lead ECG
•CHEST X Ray –PA view
•CRP, D-DIMER
•S. FERRITIN, S.LDH
•PROCALCITONIN
•TROP – I & T
•PT/INR
•ABG
•CT Thorax (if Available)
•Blood culture (if total
count is high)
•IL – 6
•S. Cortisol
•S.Mg2+, S.Ca2+
•2D
ECHOCARDIOGRA
PHY
•NTproBNP
•HsCRP
•S. Lactate
•COVID Antibody
IgM/IgGTests
Repeat
Daily _
Complete Blood Count, LFT,
RFT
ABG
Complete Blood Count, LFT,
RFT
ABG
Repeat
Every 72hrs If initial D-Dimer is
high
CRP, D-DIMER
S. FERRITIN, S.LDH
Chest X ray
CRP, D-DIMER
S. FERRITIN, S.LDH
Chest X ray
At the time
of discharge _
CRP, D-DIMER
S. FERRITIN, S.LDH
Chest X ray
CRP, D-DIMER
S. FERRITIN, S.LDH
Chest X ray
RT-PCR – Nasal & Throat
swab
Other Investigations should be done based on patient’s Co-morbid status
IDENTIFICATION OF HIGH-RISK PATIENT
CO MORBIDITIES CLINICALLY LABORATORY VALUE
Age>50 yrs Hypoxia- SPO2<94% Lymphopenia (<20) with
Neutrophil/Lymphocyte ratio >17
Ischecmic Heart Disease Tachycardia>100/min CRP>100 mg/L
Diabetes Respiratory Distress RR>30/min Serum Ferritin >300 microg/L
Hypertension Hypotension
Systolic BP < 90mmHg
LDH >450
Lung Disease (COPD/Asthma/Post
TB Sequele)
Altered Sensorium D-Dimer > 1000ng/ml
Chronic Kidney Disease/ Chronic
Liver Disease
Immunosuppression / HIV /
Malignancy
Obesity
Note: Calculation tool for predicting critically ill COVID-19 at admission can be used as reference tool. (Development of Validation of Clinical risk
score to predict the occurrence of critical illness in hospitalised patient with COVID19. JAMA internal Medicine –published online, May 12/05/2020)
GENERAL MEASURES AND GUIDELINES
1) Categorize in to A, B, C based on Symptoms, SpO2 & Respiratory Rate
2) Supportive Care:
3. • Finger Pulse Oximeter for continuous monitoring of Heart rate and Oxygen saturation
• Start oxygen with Mask at saturation of 94% or lower
• HFNC to be used if there is failed oxygen therapy and Non-invasive ventilation (NIV) to be used appropriately with two limb circuit
expiratory filters
• Counselling of COVID19 patients ( By Counsellor/psychologist/psychiatrist)
• Normal feeding, no dietary restrictions, good oral hydration
• Maintenance IV fluids (If indicated)
• Maintain blood glucose levels <180 mg/dl.
• If Patient is on ACE inhibitors/ARBs, should be continued
• Avoid using NSAIDs other than Paracetamol Unless Absolutely Necessary
• Avoid using Nebulized drugs to avoid aerosolization of virus. PREFER MDI with SPACER
• Antibiotic selection in case of superadded bacterial pneumonia should be according to institution antibiogram.
GROUP A - MILD CASES
TREATMENT PRECAUTIONS
ANTIVIRAL THERAPY
• TAB HYDROXYCHLOROQUININE(HCQ)
400MG BD FOR 1 DAY Followed by 200MG
1-0-1 X 4 DAY for patients in COVID
CARE CENTER/HOME ISOLATION
(OR)
Tab FAVIPIRAVIR 1800mg 1-0-1 on Day 1
f/b 800mg 1-0-1 for 6 days (total 7 days) for
PATIENTS IN DCHC
(OR)
If Tab HCQ/Tab FAVIPIRAVIR is
contraindicated, then combination of
Cap DOXYCYCLIN 100mg 1-0-1 for 5 days
+
Tab IVERMECTIN 12mg 1-0-0 for 3 days
· Cap Oseltamavir 75mg 1-0-1 for 5
days ANTICOAGULATION
• Inj ENOXAPARIN 40mg S/C 1-0-0 X 7 DAYS
(IF D-DIMER IS MORE THAN 1000NG/ML
(OR) X-RAY/CT THORAX SHOWING
GROUND GLASS OPACITIES)
SUPPORTIVE THERAPY-
• TAB ZINC 50 MG 0-1-0 X 7 DAYS
• TAB VITAMIN C 500 MG 1-1-1 X 7 DAYS
• Tab N Acetylcysteine 600mg 1-1-1 If Patients
Having Cough
• CATEGORIZATION SHOULD BE
REASSESSED REGULARLY
• CONTRAINDICATION FOR HCQ-
• QT INTERVAL > 480ms
• Pre-existing cardiomyopathy and
cardiac rhythm disorders
• History of Unexplained Syncope
• Retinopathy,
• Hypersensitivity to HCQ or 4-
aminoquinoline compounds
• G6PD deficiency
• Epilepsy
• Hypokalemia (K+ < 3 Meq)
• Contraindications for Tab FAVIPIRAVIR:
Hyperuricaemia, severe hepatic & renal
impairment, Pregnant women and lactating
mothers
• PREGNANCY IS NOT A
CONTRAINDICATION FOR HCQ
• # Cap OSELTAMAVIR is advised due to
possibility of H1N1 co infection along with
COVID19 disease with present weather
condition. Its usage will be reviewed at a later
date.
GROUP B - MODERATE CASES
TREATMENT PRECAUTIONS
ANTIVIRAL THERAPY
· Inj REMDESIVIR 200 mg IV on day 1 followed
by 100 mg IV daily for 4 days (total 5 days)
IF REMEDESVIR IS NOT AVAILABLE TO
START TAB
HYDROXYCHLOROQUININE(HCQ) 400MG
BD FOR 1 DAY followed by 200MG 1-0-1 X 4
DAY
Co-administration of Inj REMDESIVIR with
HCQ or chloroquine should be avoided
· Cap Oseltamavir 75mg 1-0-1 for 5
days STEROIDS
• Inj. Methyl Prednisolone 0.5 -1 mg/kg
(or)
Inj. Dexamethasone 0.1 – 0.2 mg/kg for 3-5 Days
ANTICOAGULATION
• Inj ENOXAPARIN 40MG S/C 1-0-0 x 7 DAYS
Contraindications for Inj REMDESIVIR:
· AST/ALT > 5 times Upper limit
of normal (ULN)
· Severe renal impairment (i.e., eGFR
< 30ml/min/m2 or need for
hemodialysis)
· Pregnancy or lactating females
· Children (< 12 years of age)
· No dose adjustment for Inj REMDESIVIR
if eGFR >30ml/min
· Formula to calculate eGFR in Adults
• eGFR, Male: (140 – age in years) × (weight in kg)
/ 72 × (serum creatinine in mg/dL);
• eGFR, Female: (140 – age in years) × (weight in
kg) × 0.85 / 72 × (serum creatinine in mg/dL)
STEROIDS
· to be started preferably within 48 hours of
admission (or) if oxygen requirement is
increasing and if inflammatory markers are
increased.
#
4. IV ANTIBIOTICS ACCORDING TO LOCAL
ANTIBIOGRAM
AWAKE PRONING
• CONVALASCENT PLASMA THERAPY: 4 to
13 ml/kg (usually 200 ml single dose given
slowly over not less than 2 hours)
SUPPORTIVE THERAPY
· TAB ZINC 50 MG 0-1-0 X 7 DAYS
· TAB VITAMIN C 500 MG 1-1-1 X 7 DAYS
· TAB N-ACETYL CYSTEINE 1-1-1 IN
PATIENTS WITH COUGH
· PATIENT SHOULD BE REASSESSED
EVERY 12 HRLY AND CONTINOUS
MONITORING OF SATURATION.
· START ON OXYGEN-NASAL PRONGS 2-
5 L/MIN or FACE MASK 5L/MIN
GROUP C - SEVERE/CRITICAL CASES
TREATMENT PRECAUTIONS
ANTIVIRAL THERAPY
· If the patient has not received Inj
REMDESIVIR, such patients can be started on
Inj REMDESIVIR.
Inj REMDESIVIR 200 mg IV on day 1 followed
by 100 mg IV daily for 4 days (total 5 days)
· Inj. TOCILUZUMAB 8mg/kg (maximum 800
mg at one time) given slowly in 100 ml NS over
1 hour; dose can be repeated once after 12 to 24
hours if needed
(Or)
Inj ITOLIZUMAB: 1st dose – 1.6mg/kg dose
iv infusion. Subsequent dose: weekly
0.8mg/kg dose infusion over 4hours if
required
· Cap Oseltamavir 75mg 1-0-1 for 5
days STEROIDS
· Inj. Methyl Prednisolone 1-2 mg/kg (or)
Inj. Dexamethasone 0.2 – 0.4 mg /kg for 5-7
Days
ANTICOAGULATION
· Inj ENOXAPARIN 1mg/kg body wt s/c 1-0-1 X
7 DAYS
PRONE VENTILLATION
Inj CEFTRIAXONE 1gm IV 1-0-1 AND CAN BE
ESCALATED ACCORDING TO LOCAL
ANTIBIOGRAM OR TREATING PHYSICIAN
CONSIDER SEPSIVAC (IF AVAILABLE) 0.3ml
INTRADERMAL ONCE A DAY FOR 3 DAYS IN
CASE OF SEPTIC SHOCK
IV Diuretics in case of evidence of Heart Failure
secondary to Myocarditis
SUPPORTIVE THERAPY
· TAB ZINC 50 MG 0-1-0X 7 DAYS
· INJ. VITAMIN C 1.5GM IV 6 HOURLY X
5DAYS
· TAB N-ACETYL CYSTEINE 1-1-1
Indication for TOCILUZUMAB/ITOLIZUMAB:-
1. IL-6 levels 50-100 fold higher thannormal
(Normal range 0 - 9.5pg/ml
2. Worsening trend of the inflammatory
markers (Ferritin, LDH, CRP)
3. Deteriorating clinical condition with
worsening of PaO2/Fio2 ratio (more than 25%
deterioration from the immediate previous
value).
Contraindications for Inj
TOCILIZUMAB/ITOLIZUMAB
PLHIV, those with active infections (systemic
bacterial/fungal), High Serum. Procalcitonin,
Tuberculosis, active hepatitis, Absolute
Neutrophil Count < 2000/mm3 and Platelet
count < 1,00,000/mm3, hepatic and renal
impairment; patients on chronic steroid
therapy, Paediatric patients <18 years old;
Pregnancy and, Nursing mothers
· PATIENT SHOULD BE CONTINOUSLY
MONITORED
· TO START ON OXYGEN WITH FACE
MASK WITH NON REBREATHING BAG @
8-10 lt/m
· BASED ON PaO2/FiO2 ratio, HIGH FLOW
NASAL OXYGEN (HFNC)/NIV SHOULD BE
GIVEN AND IF PATIENT DETERIORATES
INTUBATION SHOULD BE CONSIDERED
AND LUNG PROTECTIVE VENTILATION TO
BE FOLLOWED AS PER ARDSnet PROTOCOL
· ABG TO BE DONE REGULARLY FOR
MONITORING OF ACIDOSIS AND
HYPOXEMIA
· INOTROPHIC SUPPORT (NORADRENALINE
– TITRATE ACCORDING TO THE MEAN
ARTERIAL PRESSURE)
· CORRECTION OF ACIDOSIS
· MAINTAIN Hb% GREATER THAN 8gm%
SUMMARY OF TREATMENT OF COVID-19PATIENTS
BASED on CLINICALCATEGORIES
MILD MODERATE SEVERE/CRITICAL
An viral Therapy*
Tab Hydroxychloroquinine(HCQ)
400mg Bd For 1 Day F/B 200mg 1-0- 1 X 4 Day
for pa ents in COVID CARE CENTER/HOME
ISOLATION
(OR)
Tab FAVIPIRAVIR 1800mg 1-0-1 on
Day 1 f/b 800mg 1-0-1 for 6 days for PATIENTS IN
DCHC
(OR)
An viral Therapy*
Inj REMDESVIR 200 mg IV on day 1 followed
by 100 mg IV daily for4 days
(Or)
IF REMEDESVIR IS NOT AVAILABLE TO START
Tab Hydroxychloroquinine(HCQ) 400mg BD
For 1 Day F/B 200mg 1-0-1 X 4 Day
Co-administra on of Inj REMDESVIR with
HCQ or chloroquine should be avoided
An viral Therapy*
Inj. TOCILUZUMAB 8mg/kg (maximum 800 mg
at one me)
given slowly in 100 ml NS over 1 hour;
dose can be repeated once a er 12 to 24
hours if needed
(Or)
Inj ITOLIZUMAB: 1 dose – 1.6mg/kg dose
iv infusion. Subsequent dose: weekly
0.8mg/kg dose infusion over 4hours if
required
st
5. If Tab HCQ/Tab FAVIPIRAVIR is contraindicated,
then combina on of
Cap DOXYCYCLIN 100mg 1-0-1 for 5
days
+
Tab IVERMECTIN 12mg 1-0-0 for 3
Days
An coagula on
Inj Enoxaparin 40mg S/C 1-0-0 x 7 days (If D-
dimer Is More Than 1000ng/Ml or X-ray/CT
Thorax Showing Ground glass opacity)
Suppor ve Therapy
Tab Zinc 50 Mg 0-1-0x 7 Days Tab Vitamin C 500 Mg
1-1-1 X 7 Days Tab N Acetylcysteine 1-1-1 If Pa ents
Having Cough
STEROIDS
Inj. Methyl Prednisolone 0.5 -1 mg/kg (or)
Inj. Dexamethasone
– 0.2 mg /kg for 3-5 Days
ANTICOAGULATION
Inj Enoxaparin 40mg S/C 1-0-0 x7 days (if Wt
>65kg, 60md 1-0-1 for 7days)
Iv An bio cs According to Local An biogram
Awake Proning
Start on oxygen –Nasal Prongs 2- 5l/min or
face mask 5l/min
CONVALASCENT PLASMA
THERAPY:
4 to 13 ml/kg (usually 200 ml single dose given
slowly over not less than 2 hours
Suppor ve Therapy
Tab Zinc 50 Mg 0-1-0x 7 Days
Tab Vitamin C 500 Mg 1-1-1 X 7 Days
Tab N Acetylcysteine 1-1-1 If Pa ents Having
Cough
STEROIDS
Inj. Methyl Prednisolone 1-2 mg/kg for 5-7
Days
(or)
Inj. Dexamethasone 0.2 – 0.4 mg /kg for 5-
7 Days
ANTICOAGULATION
Inj Enoxaparin 1 Mg/Kg Body Weight S/C 1-
0-1 X 7days
Inj Ce riaxone 1 Gm Iv 1-0-1 And Can Be
Escalated According To Local An biogram
Or Trea ng Physician
Start on oxygen with face mask+NRM
and change over to HFNC/NIV (based on
PaO2/FiO2)
IF PATIENT DETERIORATES with
HFNC/NIV trial (repeat ABG a er 6hrs
suggests worsening of oxygena on) then
EARLY INTUBATION SHOULD BE
CONSIDERED AND LUNG PROTECTIVE
VENTILATION TO BE FOLLOWED AS PER
ARDSnet PROTOCOL
Prone Ven lla on SEPSIVAC 0.3ml
INTRADERMAL
ONCE A DAY FOR 3 DAYS
Suppor ve Therapy
Inj. Vitamin C 1.5gm Iv 6 Hourly X 5 days
Tab Zinc 50 Mg 0-1-0x 7 Days Tab N
Acetylcysteine 1-1-1 IfPa ents
Having Cough
1. Con nous monitoring of oxygen satura on by pulse oximeter and early diagnosis of hypoxemia is essen al in all group of pa ents
2. Indica ons and contraindica ons of the drugs are to be considered before use which is men oned in detail below
3. Transi on of pa ents between the clinical categories is based on SpO2, RR & PaO2/FiO2 ra o
4. Treatment of all co morbid illness to con nue
Special Note:
· *Cap Oseltamavir 75mg 1-0-1 for 5 days to be added to patients of all categories
· All the investigational therapies and drugs approved recently by DGCI should be used with caution and after informed consent from the patient
1. Hydroxychloroquine (HCQ)
Dose: Tab HCQ 400MG BD FOR 1 DAY Followed by 200MG 1-0-1 X 4
Days
CONTRAINDICATION FOR HCQ
• QT INTERVAL > 480ms
• Pre-existing cardiomyopathy and cardiac rhythm disorders
• History of Unexplained Syncope
• Retinopathy,
• Hypersensitivity to HCQ or 4-aminoquinoline compounds
• G6PD deficiency
• Epilepsy
• Hypokalemia (K+ < 3 Meq)
2. Anticoagulant Agents
Pro Coagulant factors are increased in COVID-19 infection and associated with increased risk of thrombosis
Pneumonia and sepsis are complicated by DIC, but although COVID-19 patients do have abnormalities of
coagulation and are not atypical of DIC.
The most marked abnormality is an elevation of D-Dimer (if D-dimer is more than 1000ng/ml) but without a
parallel fall in platelet or prolongation of clotting time, this suggests that local rather disseminated thrombin
generation and fibrinolysis is taking place
Dose:
Inj ENOXAPARIN 40MG S/C Once daily for mild and moderate. Twice daily in severe cases.
Other options:
• Inj Fondaparinux 2.5mg OD SC
• Unfractioned Heparin 5000 Units BD SC
Contraindications:
ESRD, active bleeding, emergency surgery, platelets < 20,000/mm3, BP
>200/120 mmHg)
INVESTIGATIONAL THERAPIES (as per MOHFW)
6. 1. Remdesivir (under Emergency Use Authorization) may be considered in patients with moderate disease (those on oxygen) with
none of the following
contraindications:
· AST/ALT > 5 times Upper limit of normal (ULN)
· Severe renal impairment (i.e., eGFR < 30ml/min/m2 or need for hemodialysis)
· Pregnancy or lactating females
· Children (< 12 years of age)
Dose: 200 mg IV on day 1 followed by 100 mg IV daily for 4 days (total 5 days)
2. Convalescent plasma (Off Label) may be considered in patients with moderate diseasewho are not improving (oxygen requirement is
progressively increasing) despite use of steroids. Special prerequisites while considering convalescent plasma include:
· ABO compatibility and cross matching of the donor plasma
· Neutralizing titer of donor plasma should be above the specific threshold (if the latter is not available, plasma IgG titer (against S-
protein RBD) above 1:640 should beused)
· Recipient should be closely monitored for several hours post transfusion forany transfusion related adverse events
· Use should be avoided in patients with IgA deficiency or immunoglobulin allergy
Dose: Dose is variable ranging from 4 to 13 ml/kg (usually 200 ml single dose given slowly over not less than 2 hours
3. Tocilizumab (Off Label) may be considered in patients with severe disease with progressively increasing oxygen requirements and
in mechanically ventilated patients not improving despite use of steroids. Long term safety data in COVID 19 remains largely
unknown. Special considerations before its use include:
o IL-6 levels 50-100 fold higher than normal (Normal range 0 - 9.5pg/ml
o Worsening trend of the inflammatory markers (Ferritin, LDH, CRP)
o Deteriorating clinical condition with worsening of PaO2/Fio2 ratio(more than 25% deterioration from the immediate
previous value)
The drug is contraindicated in
PLHIV, those with active infections (systemic bacterial/fungal), High Serum. Procalcitonin, Tuberculosis, active hepatitis, Absolute
Neutrophil Count < 2000/mm3 and Platelet count < 1,00,000/mm3, hepatic and renal impairment; patients on chronic steroid therapy,
Paediatric patients <18 years old; Pregnancy and, Nursing mothers
Dose: 8mg/kg (maximum 800 mg at one time) given slowly in 100 ml NS over 1 hour; dose can be repeated once after 12 to 24 hours if
needed
Drugs Recently approved by DGCI
1. ITOLIZUMAB (An anti-CD6 IgG1 monoclonalantibody) Indication:
1. IL-6 levels 50-100 fold higher than normal (Normal range 0 - 9.5pg/ml
2. Worsening trend of the inflammatory markers (Ferritin, LDH, CRP)
3. Deteriorating clinical condition with worsening of PaO2/Fio2 ratio (more than 25% deterioration from the immediate previous
value).
Dose: 1st dose – 1.6mg/kg dose iv infusion
• Subsequent dose: weekly 0.8mg/kg dose infusion over 4hours if required based onlung function parameters
Contraindication:
PLHIV, those with active infections (systemic bacterial/fungal), High Serum. Procalcitonin, Tuberculosis, active hepatitis, Absolute Neutrophil
Count < 2000/mm3 and Platelet count < 1,00,000/mm3, hepatic and renal impairment; patients on chronic steroid therapy, Paediatric patients
<18 years old; Pregnancy and, Nursing mothers
Side effects:
• In trial Infusion reactions have been reported in 15% of the patients
• In clinical practice also infusion reaction ranged from 12% to15%
• Other adverse events include Diahorea, Pruritus in 7 – 12 % of cases
2. Tab. FAVIPIRAVIR
Mechanism of action: It is considered that favipiravir is metabolized in cells to a ribosyl triphosphate form (favipiravir RTP) and that
favipiravir RTP selectively inhibits RNA polymerase involved in influenza viral replication
Indications: mild to moderate cases of COVID19 in adults >18yrs old
Dose: 1800mg bid followed by 800mg bid upto maximum of 14days
Contraindications: Hyperuricaemia, severe hepatic & renal impairment, Pregnant women and lactating mothers
Side Effects: increased Uric Acid levels, diarrhea, decreased neutrophil counts, increase in AST/ALT levels
Drug Interactions: metabolised partly by Aldehyde Oxidase(AO) and partly by Xanthine Oxidase(XO). Precauitons for co-administration
with Pyrazinamide, Repaglinide, Theophyline, Famciclovir
PRONE VENTILATION
Early self-proning in awake, non-intubated patients – Moderate cases
· Any COVID-19 patient with respiratory embarrassment severe enough to be admitted tothe hospital may be considered for rotation and
early self-proning.
· Care must be taken to not disrupt the flow of oxygen during patient rotation
Criteria to be fulfilled Avoid proning
7. · Patients with oxygen
requirement of >4L
· Normal mental status
· Able to self-prone or change
position with minimal assistance
· Hemodynamic instability
· Close monitoring not possible
· Typical protocols include 30–120 minutes in prone position, followed by30–120 minutes in left lateral decubitus, right lateral decubitus,
and upright sitting position
(Caputo ND, Strayer RJ, Levitan R. Academic Emergency Medicine 2020;27:375–378)
Requirements for safe prone positioning in ARDS
· Pre-oxygenate the patient with FiO2 1.0
· Secure the endotracheal tube and arterial and central venous catheters
· Adequate number of staff to assist in the turn and to monitor theturn
· Supplies to turn (pads for bed, sheet, protection for the patient)
· Knowledge of how to perform the turn as well as how to supine the patient in case ofan emergency
Contraindications to prone ventilation
· Spinal instability requires special care
· Intra cranial pressure may increase on turning
· Rapidly return to supine in case of CPR or defibrillation
When to start proning in SEVERE CASES?
· P/F ratio <150 while being ventilated with FiO2 >0.6 and PEEP >5 cm H2O When to stop proning?
· When P/F exceeds 150 on FiO2 > 0.6 and > 6 PEEP
What portion of the day should patients be keptprone?
· As much as possible (16-18 hours a day)
· Adult patients with severe ARDS receive prone positioning for more than 12 hours perday (strong recommendation, moderate-high
confidence in effect estimates)
(ATS-ERS Guideline. Am J RespirCrit Care Med;2017;195(9):1253-1263)
Oxygen delivery protocol
• SpO2 < 94% ~ Supplement with nasal prongs or simple face mask at 2-5L/min
• Monitor continuous SpO2 with finger pulse oximetry
• If SpO2 < 94% on simple face mask or nasal prongs, change to non-rebreather mask oxygen (NRB) at 10-15L/min
• Oxygen Delivery Devices & approximate FiO2%
8. HFNO (High Frequency Nasal Oxygen) and NIV (Non-invasive Ventilation)
• When oxygen requirement increases to needing NRB, options of High Frequency Nasal Oxygen (HFNO) or NIV should be
considered.
• HFNC flow rates to be set from 30 -60 L/min titrating to maintain SpO2 ≥ 92%
•
HFNC provides PEEP up to 5-6 cm H20 and can deliver FiO2 up to 100%
• If HFNC non-available or patient not maintaining SpO2 on flow rates up to 60L/min, initiate on non-invasive ventilation (NIV)
only with an ICU ventilator with two limbed circuit and expiratory HME filter with a NIV mode available. Caution is to be exercised to
not use potable home BiPAP or CPAP machines with single circuit for these patients.
· Appropriate mask with good seal to be ensured when initiated on NIV. Helmetmasks/hoods if available, to be preferred to minimize
aerosol contamination.
· Once initiated on NIV, close monitoring of respiratory variables hourly is important.
· Reassess clinical condition hourly, monitor and observe ABG’s 4-6hrly
· Look for signs of clinical improvement in the form of settling tachycardia, improvingSpO2, reduced tachypnea and reduced work of
breathing.
· On NIV when there are signs of clinical deterioration in the form of worsening sensorium, increased accessory muscles of breathing, raising
Pco2, worsening pH on ABG ~ failure of NIV has to be considered and patient has to be planned for intubation and mechanical ventilation
after consent from the family.
Intubation and Mechanical Ventilation
· Indication for intubation: ARDS with PaO2/FiO2 < 200
· Worsening respiratory distress even on NIV
· Patient in Shock
Initial Settings: Controlled Mode ventilation: VCV (volume-controlled ventilation) or PCV (pressure-controlled ventilation)
· Tidal Volume (Vt) 6-8ml/PBW (predicted body weight)
· PEEP 8 – 18 cmH2O (follow FiO2-PEEP table) to titrate to target SpO2 90-92%
· FiO2 ~ target SpO2 90-92% with lowest FiO2 possible
· Respiratory rate 14-18/min (maximum up to35/min)
· Plateau pressure < 30 cmH2O and driving pressure < 16cmH2O
· ABG targets: PaO2 55-80 mmHg, pH > 7.3
· Measure compliance 6hrly ~ Vt in ml /Pplat – PEEP
Notes:
Additional steps: If Pplat > 30cmH2O, reduce Vt upto 4ml/PBW
· If SpO2 < 88% despite ARDSnet protocol: increase depth of sedation
· Optimize secretions clearance/bronchodilation
9. Indication for prone ventilation:
· Intubation and mechanical
ventilation < 36hrs
· PaO2/FiO2 < 150, FiO2 > 60%,
PEEP > 5, Vt 6ml/PBW
· Duration of proning: 12-16 hrs.
· Multiple sessions until
favorable trends are achieved.
· Initiate early muscle relaxant infusion (cis-atracurium or vecuronium)
· Early prone ventilation
Adjunctive measures when intubated and mechanically ventilated:
Ø Antibiotics guided by protocols
Ø Steps to reduce VAP (ventilator associated pneumonia) by following VAP bundles
Ø Head-end elevation
Ø Thrombo-prophylaxis
Ø Adequate analgesia and sedation
In absence of ABG facility at the hospitals, use SpO2/FiO2 ratio as described in the below table
REFERENCES:
1. CLINICAL MANAGEMENT PROTOCOL: COVID-19 Government of India Ministry of Health and Family Welfare Directorate
General of Health Services (EMR Division) Version 5. 03.07.20
2. Development of Validation of Clinical risk score to predict the occurrence of critical illness in hospitalised patient with COVID19. JAMA
internal Medicine –published online, May 12/05/2020
3. FACT SHEET FOR HEALTH CARE PROVIDERS EMERGENCY USEAUTHORIZATION (EUA) OF REMDESIVIR (GS-5734™
4. TOCILIZUMAB Drug Monograph
5. ITOLIZUMAB Drug Monograph
6. FAVIPIRAVIR Drug Monograph
7. Matthew Wemple / Joshua O. Benditt. Fishman’s Pulmonary Diseases and Disorders.Fifth Edition.
8. Pratik P. Pandharipande et al. Derivation and validation of SpO2/FiO2 ratio to impute for PaO2/FiO2 ratio in the respiratory
component of the Sequential Organ FailureAssessment (SOFA) Score. Crit Care Med. 2009 April ; 37(4): 1317–1321.
doi:10.1097/CCM.0b013e31819cefa9