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