*Nice compilation by KEM Mumbai*……… Released from KMC ::
Once covid is diagnosed get a baseline CBP, LFT, RFT, CRP, d-Dimer, IL6 (if available), LDH, Ferritin, Trop-T, ECG, baseline CXR and CT chest.
Ask for replication score in RT PCR test. It indicates how infective you are for other people. Any score above 25 is generally non-infectious especially if you crossed 10 days & asymptomatic for 3 consecutive days.
Viral replication generally stops by 9th day which means if you want any benefit of anti-viral it should be given within 9 days. There is doubt regarding the efficacy of Remdesevir if given late.
RT PCR may be negative in late stages of infection. So dont forget to rely on clinical, epidemiological and radiological guidance to DIAGNOSE A CASE !!
Best time for RT PCR after symptom onset 5th to 8th day. False negatives lowest in these days.
The pathology of Covid disease is that the inflammation which causes damage not virus.
Covid , SLE, APLA, TIDM Macrophage activation syndrome , HLH are all similar… Host immune system reacts against its own tissues… Covid has a know antigen SARS CoV2… “” Frustrated phagocytosis ‘” occurs when the antigen cannot be eliminated leading to hyperactivation of macrophages and lymphocytes leading to destruction of tissues.
Even CT changes occur a little late but CRP and LDH are the first to raise. Clinically the 3 dangerous symptoms are fever , myalgia and exhaustion which indicate high inflammation in the body.
Steroids and anti coagulation are going to be the CORNER STONE of treatment.
At present steroids are recommended for people who become hypoxic. Start early steroid irrespective of hypoxia especially if CRP and other inflammatory markers are elevated.
Oral prednisolone 20mg or Tab Dexa 4mg /day for 5 to 7 days will do the job if there are mild symptoms.
Steroids will definitely make patient feel better.
Steroids also prevent long term lung fibrosis.
Regarding anti coagulation Inj Clexane 0.5mg s/c bd if d -Dimer is normal and 1mg s/c bd if d-Dimer is elevated.
There is a controversy regarding when to start anticoagulant.
Better to start it early if CT changes are seen, as the changes in CT are actually microvascular thrombi.
After 5 days, you can switch to oral anticoagulant Tab Rivaroxaban 10mg OD for 4 weeks.
Early steroids and anticoagulant will prevent longterm complications.
It may not make difference in acute phase.
If there is hypoxia both are mandatory.
Preferable Inj Methylprednisolone 40mg iv bd or tid based on weight and severity of hypoxia.
HCQ should not be combined with Remdesevir.
Switch to oral Dexa once course of anti viral is finished.
Steroids may be needed for 2 to 3 weeks if hypoxia is present.
Is preferable to prolong anticoagulant for 6 weeks if oxygen is needed.
It is mandatory to monitor CRP, D Dimer every alternate day till patient is in hospital.
IL6 on day 5 and day8.
Any raise in IL6 is a marker for an impending cytokine storm and ensure to have access to Tocilizimab if symptoms worsen.
IL6 can return to normal with steroids and anticoagulant.
Most dangerous period is 8 to 12 days.
That is when most people die.
There are rare reports of late cytokine storm after 12 days.
But if treatment is started early as mentioned above it is very unlikely patient will land up in complications.
Again to reiterate it is inflammation which kills, not virus.
Hit inflammation hard and early and be alive for 2 weeks.
Body will automatically clear the virus after that.
Prone ventilation for 18 hours a day will make a big difference if patient is hypoxic.
No need to repeat CT chest after baseline.
CXR every 3 days is sufficient to monitor progress.
Remember radiological changes may take weeks or months to clear. Don’t get panicked. Remember they are blood clots not regular pneumonia.
Improvement in oxygen levels is the marker for clinical improvement.
No need to monitor anything else once oxygen starts improving.
If Tocilizimab is given keep monitoring procalcitonin for secondary infection and the risk of infection is present or for n ext 2 weeks.
Once Tocilizimab is given patient don’t manifest fever or raised counts as marker of infection.
Keep a low threshold for antibiotic if patient received Tocilizimab.
It’s might be better not to use any antibiotic in Covid illness.
Patients will do absolutely well without antibiotic provided you keep changing lines regularly and stop IV medications early.
Don’t forget Dexamethasone is highly pro diabetic.
So even if sugars are normal in first week keep monitoring blood sugars regularly as long as patients are on steroids.
10 to 15% dont develop antibodies post covid. Reason for it are probably some truly dont develop antibodies, or develop some T cell immunity, or dominant IgA antibody response in respiratory mucosa and not systemic IgG response.
So post covid immunity passport is INVALID