*Summary of COVID Rx updated guideline*

*Summary of COVID Rx updated guideline*

(Adopted from webinar held on 25/4/2021 conducted by Dept of H & FW, Govt of West Bengal, Presented by Prof Soumitra Ghosh, HOD Medicine, IPGME & R, Kolkata)

*Virus doesn’t kill directly, it kills by immune inflammation.*

Treatment must centre on the monitoring of clinical, biochemical and inflammatory parameters.

*Fight inflammation at right time.*

*Stages of COVID Course*

1. Active Viral Replication, 2. Immune inflammation, 3)IMMUNE HYPER-INFLAMMATION, 4) Organ damage, 5) Multi-organ dysfunction, 6) Death.

*The cytokine storm begins from stage 2 to stage 3.*

Management step up: 3 pillars;

1. DIAGNOSIS,

2. CLINICAL & BIOCHEMICAL

3. MONITORING, TREATMENT WITH PCM, IVERMECTIN, DOXYCYCLINE, Zn & Vit C.*

Monitoring: i) clinical, ii) SpO2 iii) CRP, iv) D-Dimer, v) CBC.

*Start Dexamethasone if a) CRP > 5X ULN, b) D-Dimer > 2X ULN, c) NLR> 3.13*

Management levels:

*LEVEL 1*= PCM, IVERMECTIN, DOXYCYCLINE, VitC, Zinc.

SpO2<95%

If there is increase in CRP, D-Dimer, NLR then moved to

*LEVEL 2*= Oxygen, dexamethasone, Anticoagulant, Comorbidity Care.

If there is Falling oxygen & Organ failure, step up to

*LEVEL 3*= BiPAP, HFNC, Ventilation, High dose steroid, Antibiotics.

*DEXAMETHASONE IS THE GAME CHANGER.*

In moderate cases, 0.1-0.2mg/kg/day (6-12 mg/d).

In severe cases, 0.2-0.4 mg/kg/day (12-24 mg).

Sequence of events >> Increasing inflammatory markers >> organ/lung damage>> decreasing PaO2>>decreasing Spo2.

Lab & clinical monitoring.

1. CBC, CRP, D-Dimer: 48-72 hrly.

2. LFT, KFT: 48-72 hrly.

3. Trop T, ECG

4. HRCT Chest/CXR (PA)

5. Change in posture (Prone).

*Warning signs to Step up (Level 3) treatment:*

1) Difficulty in breathing, 2) Persistent fever/High grade fever, 3) Recurrence of fever after remission, 4) Palpitations, 5) Chest pain/chest tightness, 6) severe cough, 7) any new onset of symptoms. 8) SpO2< 90% in room air, 9) CRP> 5 times of ULN, 10) D-dimer > 2 times of ULN, 11) NLR> 3.13.

*Oxygen prescription:*

Nasal canula (2-4 liters/min)

Face Mask (6-10 liters/min)

NRBM (10-15 liters/min)

HFNC (25-60 liters/min)

Ventilator (10 liters/min)

Target SpO2 94-95%, not above 97%, there will be wastage of this precious gas.

Once achieved, flow rate shouldn’t be increased (no addl benefit).

*Management in a nutshell:*

1. Antipyretics: PCM for fever.

2. Steroid IV Dexamethasone (oral route and prednisolone are not as effective) 0.1-0.2 MG/KG for at least 5-10 days.

3. Oxygen support Target SpO2 (94-95%), , >90% in pts with COPD.

4. Oxygen flow rate & oxygen delivery device (Canula, Face Mask, NRBM,BiPAP, HFNC, Ventilation).

5. Conscious proning when hypoxia persists, position change @ 1-2 hrs.

6. Anticoagulation, prophylactic use of UFH or LMWH (Enoxaparin 40 mg/day SC).

7. Antivirals: Remdesivir-oxygen requiring moderate disease of < 10 DAYS. Not to start after 10 days.

8. Convalescent Plasma: Not great. May be considered in selected cases.

9. Antibiotics: Jidiciously use as per Antibiotic protocol.

10. Fight inflammation in Right time-key slogan to save life.

11. Dexamethasone in right time is the Game Changer.

12. Don’t give Steroid in Early Viral Replicative Phase.

13. *“Cat Like Observation” & “Timely Step up”*

14. *Be Positive and smart, Respect Autonomy.*

Summarized by Dr Ranjan Bhattacharyya. 🙏🙏

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