Latest covid protocol

Published by Department of Health & Family Welfare, Govt of West Bengal LABORATORY CONFIRMED COVID 19 PATIENT

 

Symptomatic patientswith the following co- morbidities

  Age>60yrs

  DM

  HTN /IHD

  COPD/Chronic lung disease

  Immunocompromised state

  Immunosuppressive drugs

  CKD

  Chronic Liver Disease

  Obesity

Symptomatic patients (irrespective of comorbid conditions) with any of the following signs:

  Fever > 100.4 F

  Respiratory rate > 22/ min

  Systolic BP <= 100 mmHg

  SpO2 <95%

  Respiratory distress

  Chest pain

  Change in mental status

  Cyanosis

1. All asymptomatic patients.

2. Comorbid patients with no symptoms (prioritise to control the comorbid state)
3. Mild symptoms (low fever, dry cough, anosmia, ageusia, weakness, diarrhea, myalgia etc) with

  No comorbidity

  Low fever (<100.4 F)

  No signs of respiratory
distress

  Normal SpO2

  Normal mental status, systolic
BP > 100 mmHg and Respiratory rate < 22/min

    

No oxygen requirement or Oxygen requirement <10 L/min

Oxygen requirement >10 L/min

  

HDU/ ICU

RESPIRATORY SUPPORT

  HFNC if work of breathing is HIGH

  A cautious trial of NIV /CPAP with full face
mask/ oronasal mask

  Consider Intubation if work of breathing is
high/ NIV is not tolerated

  Lung protective ventilation strategy by
ARDS net protocol

  Prone ventilation in refractory Hypoxemia
STEROID
Dexamethasone 0.2 to 0.4 mg/kg for at least 5-10 days
ANTICOAGULATION
Prophylactic dose of UFH or LMWH (e.g. Enoxaparin 0.5 mg/kg BD SC), if not at high risk of bleeding (consider UFH if CrCl<30)
ANTIVIRAL
Antiviral agents are less likely to be beneficial at this stage; use of Remdesivir to be decided on case to case basis, Not to start after 10th days of symptom onset /Test date
TOCILIZUMAB may be considered on a case to case basis after shared decision making
ANTIBIOTICS should be used judiciously as per Antibiotic protocol
INVESTIGATIONS
Essential investigations along with Cultures (Blood / Urine), FBS, PPBS, CBC, CRP, Ferritin, D-Dimer, Trop-T/ Quantitative Troponins, Procalcitonin, Coagulation Profile, HRCT Thorax.
SUPPORTIVE MEASURES
• Maintain euvolemia
• Sepsis/septic shock: manage as per

protocol and antibiotic policy
• Sedation and Nutrition therapy along with

as per existing guidelines (FAST HUGS)

HOME ISOLATION/ SAFE HOME

MONITOR: Temp, Pulse, BP, SpO2, Sensorium

  Preferable Investigations: CBC, CRP, D-Dimer

  ECG, CBG, Serum Creatinine: as required

  Supportive Management

  Mask, Hand Hygiene, Physical
distancing, droplet precaution

  IVERMECTIN 12 mg OD for 5
Days AND

  DOXYCYCLINE 100mg BD for 5-
7 days

  PARACETAMOL for fever,
bodyache

  Vit C, Zinc

  Laxative (if required)

  Steroids should NOT be used
routinely in patients with mild disease

Warning Signs

  Difficulty in breathing

  Persistent Fever/ High grade
fever

  Recurrence of Fever

  Palpitations

  Chest pain/ Chest tightness

  Severe Cough

  Any new onset symptoms

  SpO2 <95% ( Room Air)

  CRP>5timesofULN

  D-Dimer > 2 times of ULN

  NLR > 3.13

  Or, as advised by physician

specially in High-Risk Group

  

COVID WARD

Pneumonia (LRTI)

WITHOUT

respiratory failure (Fever/ cough/ dyspnea & SpO2 ≥95% on room air, PaO2 > 60 mmHg & RR< 24/min)

Pneumonia (LRTI) WITH respiratory failure (RR> 24 /min,
SpO2 < 95% on room air,

PaO2 < 60 mmHg)

RED FLAG SIGNS

1. NLR > 3.13
2. CRP > 5 times of ULN
3. D-Dimer > 2 times of ULN

RED FLAG SIGNS
1. SBP<100
2. Altered sensorium 3. Raised Troponin-I / CPK-MB

4. P:F ratio <200
5. Sepsis/ Septic Shock 7. Multi Organ Dysfunction Syndrome 8. Rapidly increasing Oxygen Demand

ANTIPYRETICS: Paracetamol for fever OXYGEN SUPPORT

  Target SpO2 ≥ 95% (≥90% in pts. with COPD)

  Any type of Oxygen delivery device (canula/
Face mask/ non-re-breathing face mask)

  Conscious proning may be used in whom
hypoxia persist despite use of high flow
oxygen. (position change at every 1-2 hours)
STEROID

Dexamethasone 0.1 to 0.2 mg/kg for at least 5-10 days

ANTICOAGULATION

Prophylactic dose of UFH or LMWH

(Enoxaparin 40mg/ day SC)

ANTIVIRAL
Inj REMDESIVIR 200 mg IV on day 1 f/b 100 mg IV daily for 5 days ( Not to start after 10th days of symptom onset/Testing date, whichever is earlier)

CONVALESCENT PLASMA may be considered in selected cases

ANTIBIOTICS (Antibiotics should be used judiciously as per Antibiotic protocol)

MONITORING

  CBC, CRP, D-Dimer: 48-72 hourly

  LFT, KFT: 48-72 hourly

  Trop T, ECG, Coagulation Profile

  HRCT Chest/ CXR – PA

  Change in oxygen requirement, Work of breathing, Hemodynamic instability

 

Admit the patient at Covid Ward/ HDU/ ICU

One comment

  1. krb2709@gmail.com · · Reply

    BEFORE PANICKING ABOUT DECISIONS TO BE MADE REGARDING COVID INFECTION TO YOURSELF OR YOUR FAMILY MEMBERS/RELATIVES/FRIENDS…KEEP THESE IN MIND👇 Lessons from the second wave. India today seems to be in the exact same situation that the UK was in mid december. First an exponential number of people testing Covid positive followed a week later by an exponential increase in number of hospitalizations followed 2 weeks later by an exponential increase in Covid deaths. Here are some of the lessons learnt

    1. 99% of Covid positive recover on their own. The only things needed for them are oxygen level monitoring to make sure sats are >93, paracetamol (Crocin or Dolo) for fever and bodyache and home isolation to make sure they do not pass it on to others. There is no need or benefit in giving plasma, remdesivir, ivermectin, hydroxychloroquine , antibiotics or even steroids, blood thinners or toclizumab to these 99%. There is NO need for hospitalization as long as oxygen levels are above 93%.

    2. Covid is an illness that affects a lot of people at the same time, however it is how severely it affects the 1% who are unlucky enough to have severe covid which makes it the dreaded illness it is. All our medical resources (hospital beds, oxygen cylinders etc) need to be saved for these severely affected 1% and not the 99% with mild illness irrespective of wealth , contacts , influence etc.

    3. For the 1% that have severe illness the only medications that have been found to have significant benefit are steroids and blood thinners. Toclizumab also has been found to have benefit (only 4%) and should be given whenever available. Remdesivir has very minimal benefit (no mortality benefit at all) and should be given if available however the patient does not loose much if not given . However it will be wrong to call either of them (toclizumab/remdesevir) life saving in Covid.

    4. Plasma has been extensively studied and found to be of no benefit. This is after painstaking analysis of 11,000 patients given plasma vs 11,000 not given plasma. It should NOT be given. It uses up a significant amount of resources with no benefit.

    5. Hydroxychloroquine/Ivermecin. No serious medical organisation is the world found any benefit in giving them and should not be given. However they are cheap and relatively harmless .

    6. Oxygen shortage – Many hospitals in the UK had to stop admitting patients due to running out of oxygen for short periods of time. We only need to give enough oxygen for levels to be above 93 to 94 . There is often a tendency to turn oxygen flows to the highest levels possible. This has to be avoided.

    7. Vaccine. In London before the vaccine all our ICUs were full, all theatre recoveries were full, all cardiac HDUs etc were full of intubated covid patients and we were transferring intubated covid patients to as far as Scotland, Bristol etc in helicopters to relieve ICU capacity in London. After the vaccine we have hardly any hospital admissions and and almost nil new ICU admissions. However this could also have been due to the serious nature of the lockdown.

    8. Rationing of resources. In the UK every patient who needed a hospital bed got one and every patient who was suitable for an ICU bed got one. This was only possible as there were strict criteria for hospital admission which meant that the 99% of Covid positive who do not need oxygen were not hospitalised. This needs to be done strictly in India as well.

    9. Once someone has tested covid positive there is no need to get retested to see if they are still covid positive. This unnecessary re testing results in wastage of testing resources. Once 2 weeks of home isolation following date of onset of symptoms is complete a person is considered covid negative and non infectious.

    Myself DR CHIRAYU VYAS MD(Gold Medalist)-DNB,DM Cardiology(AIIMS,NEW DELHI)…Cardiac Electrophysiologist(PDF) & Interventional Cardiologist.

    Like

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