COVID-19

Management with New Protocol

Prof. Soumitra Ghosh

MD (Cal), FRCP (Edin), FACE (USA), FACP (USA), SCOPE (UK) MD, FRCP (Edin), FACE (USA), DTCD, FICP

MSc. Diabetes (UK), PG.Dip Diabetes (UK), DTCD (Cal), FICP Professor of Medicine

Head, Obesity & Lifestyle Diseases Division Institute of Post-Graduate Medical Education & Research SSKM, Belle Vue & Nightingale Hospital, Kolkata

   

Prof. Soumitra Ghosh

COVID-19 : How it Kills

Virus Does Not Kill Directly
It kills By Immune Inflammation

Treatment Must Centre Around the monitoring of Clinical and Biochemical Inflammatory Parameters

Fight Inflammation at Right time

      

Prof. Soumitra Ghosh

Stages of COVID Course

1. Active Viral Replication

2. Immune Inflammation

3. Immune Hyper-inflammation

4. Organ Damage

5. Multi-organ Dysfunction

6. Death

            

Prof. Soumitra Ghosh

Right Time to Fight COVID

1. Active Viral Replication

2. Immune Inflammation X

         

3. Immune Hyper-inflammation

4. Organ Damage

5. Multi-organ Dysfunction

6. Death

Cytokine Storm

      

Prof. Soumitra Ghosh

  

1. 2. 3.

4. 5. 6.

Same As the Principles of “Fire Fighting”

Active Viral Replication

Immune Inflammation X

Immune Hyper-inflammation

InFlammation Term coined from Flame Organ Damage

Multi-organ Dysfunction Death

              

Prof. Soumitra Ghosh

Same As the Principles of “Fire Fighting”

1. Active Viral Replication

2. Immune Inflammation X

3. Immune Hyper-inflammation

4. Organ Damage

5. Multi-organ Dysfunction

6. Death

                

Prof. Soumitra Ghosh

How to Identify the Ignition

     

2. Immune Inflammation
3. Immune Hyper-inflammation

X

        

Increasing CRP, D-Dimer, N : L Ratio

 

Prof. Soumitra Ghosh

Management Step Up

 

Diagnosis

Prof. Soumitra Ghosh

When to Step Up the Management

 

Clinical SpO2

CRP D-Dimer

CBC

  

Paracetamol

Diagnosis

Ivermectin, Doxycycline, Zn, Vit-C

Prof. Soumitra Ghosh

When to Step Up the Management

  

Clinical SpO2

CRP D-Dimer

CBC

Dexamethasone

 

CRP > 5 x ULN



D-Dimer > 2 x ULN



NLR > 3.13

  

Paracetamol

Diagnosis

Ivermectin, Doxycycline, Zn, Vit-C

Prof. Soumitra Ghosh

When to Step Up the Management

  

Oxygen

Dexamethasone

  

Clinical SpO2

CRP D-Dimer

CBC



NLR > 3.13

CRP > 5 x ULN

 

SpO2 < 95

D-Dimer > 2 x ULN

   

Paracetamol

Diagnosis

Ivermectin, Doxycycline, Zn, Vit-C

Prof. Soumitra Ghosh

When to Step Up the Management

   

Oxygen

Anti-coagulant

Dexamethasone

   

Clinical SpO2

CRP D-Dimer

CBC



NLR > 3.13

CRP > 5 x ULN

 

SpO2 < 95

D-Dimer > 2 x ULN

   

Paracetamol

Diagnosis

Ivermectin, Doxycycline, Zn, Vit-C

Prof. Soumitra Ghosh

When to Step Up the Management



  

Oxygen

Anti-coagulant

Dexamethasone



Clinical SpO2

CRP D-Dimer

CBC



CRP > 5 x ULN

 

SpO2 < 95

D-Dimer > 2 x ULN



NLR > 3.13

  

Paracetamol

Diagnosis

Ivermectin, Doxycycline, Zn, Vit-C

Prof. Soumitra Ghosh

Three Management Levels

 

Paracetamol, Ivermectin, Doxycycline, Vit-C, Zinc

LEVEL – 1

Prof. Soumitra Ghosh

LEVEL – 2

Three Management Levels

 

Oxygen, Dexamethasone, Anti-Coagulant, Comorbidity Care

  

SpO2 < 95

↑↑ CRP, D-Dimer, NLR



Paracetamol, Ivermectin, Doxycycline, Vit-C, Zinc

LEVEL – 1

Prof. Soumitra Ghosh

Three Management Levels

 

BiPAP, HFNC, Ventilation, High Dose Steroid, Antibiotics

LEVEL – 3

  

Falling Oxygen

Organ Failure



Oxygen, Dexamethasone, Anti-Coagulant, Comorbidity Care

LEVEL – 2

  

SpO2 < 95

↑↑ CRP, D-Dimer, NLR



Paracetamol, Ivermectin, Doxycycline, Vit-C, Zinc

LEVEL – 1

Prof. Soumitra Ghosh

FIGHT Inflammation at RIGHT Time

Dexamethasone is the Game Changer



Prof. Soumitra Ghosh

FIGHT Inflammation at RIGHT Time

Dexamethasone is the Game Changer

• Moderate 0.1 – 0.2 mg/kg/day ( 6 – 12 mg /day ) • Severe 0.2 – 0.4 mg/kg/day ( 12 – 24 mg /day )



Prof. Soumitra Ghosh

PREVENT Hospitalisation, Oxygen and DEATH

Dexamethasone is the Game Changer



If Started in RIGHT Time, in HOME ISOLATION phase

We can AVOID HOSPITALISATION, OXYGEN REQUIREMENT and DEATH

Prof. Soumitra Ghosh

FIGHT Inflammation at RIGHT Time

• COVID has an Unpredictable Course

• It is Possible to Make it Predictable

• Nothing Happens Suddenly

• We Need to Demystify COVID



Prof. Soumitra Ghosh

Sequence of Events

    

Inflammation Lung Decreasing Decreasing Markers Rising Damage PaO2 SpO2

Decreased SpO2 is a very Late Finding

Act Before This Stage to Save Life

  

Prof. Soumitra Ghosh

Sequence of Events

    

Inflammation Lung Decreasing Decreasing

  

Rising Markers Damage PaO2

Start Dexamethasone Here

SpO2

Do Not Wait Till Here

 

Prof. Soumitra Ghosh

Laboratory and Clinical Monitoring to Guide Treatment

• CBC, CRP, D-Dimer : every 48 – 72 hourly

• LFT, KFT : every 48 – 72 hourly

• Trop T, ECG

• HRCT Chest / CXR – PA

• Change in Oxygen Requirement, Work of Breathing

• Hemodynamicinstability



Prof. Soumitra Ghosh

Warning Signs to Step Up 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 symptoms

8. SpO2 <95% ( Room Air)

9. CRP > 5 times of ULN

10. D-Dimer > 2 times of ULN

11. NLR > 3.13

12. Or, as advised by physician specially in High-Risk Group



Prof. Soumitra Ghosh

Warning Signs to Step Up 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 symptoms

8. SpO2 <95% ( Room Air)

9. CRP > 5 times of ULN

10. D-Dimer > 2 times of ULN

11. NLR > 3.13

12. Or, as advised by physician specially in High-Risk Group

 

Prof. Soumitra Ghosh

Oxygen is A Drug – Needs Prescription



1. Nasal Canula ( 2 – 6 Litters/min )

2. Face Mask ( 6 – 10 Litters/min )

3. Non Rebreathing Mask ( 10 – 15 Lit/min )

4. BiPAP (25-60Litters/min)

5. HFNC (25-60Litters/min)

6. Ventilator (10Litters/min)

• Target SpO2 94 % ± 2 % for admitted COVID pts.
with Oxygen

• Once achieved, flow rate should not be increased as it does not provide any additional benefit

Prof. Soumitra Ghosh

Management



1. ANTIPYRETICS: Paracetamol for fever

2. STEROID • Dexamethasone 0.1 to 0.2 mg/kg for at least 5-10 days

3. OXYGEN SUPPORT

• Target SpO2 ≥ 95% (≥90% in pts. with COPD)
• Oxygen Flow Rate and Oxygen delivery device (Canula/Face mask/NRBM / BiPAP/HFNC/Ventilation/ECMO) • Conscious proning when hypoxia persist despite high flow oxygen (position change @ 1-2 hours)

4. ANTICOAGULATION • Prophylactic dose of UFH or LMWH (Enoxaparin 40mg/day SC)
5. ANTIVIRAL • REMDESIVIR – Oxygen Requiring Moderate Disease of < 10 days. Not to start after 10 days 6. CONVALESCENT PLASMA • Not Great. Overhyped. May be considered in selected cases
7. ANTIBIOTICS • Judiciously Use as per Antibiotic protocol

Prof. Soumitra Ghosh

Management

• Fight Inflammation in Right Time – Key Slogan to Save Life

• Dexamethasone in Right Time is the Game Changer

• Don’t Give Steroid in Early Viral Replicative Phase

• “Cat Like Observation” and “Timely Step Up”

 

Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Things to Care • Inflammation

• Oxygen
• Comorbidity Care



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Levels of Management

• Non Oxygen Requiring Mild Disease

• Low Oxygen Requiring Moderate Disease

• High Oxygen Requiring Severe Disease



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Clinical Parameters for Monitoring • Temperature

• Blood Pressure • SpO2



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Laboratory Parameters for Monitoring • CRP

• D-Dimer
• N : L Ratio ( CBC )



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Drugs to Begin with at Level 1 • Paracetamol

• Ivermectin • Doxycycline



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Drugs to Step up in Level 2 • Dexamethasone

• Oxygen
• Anticoagulant



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Drugs to Step up in Level 3

• High Dose Dexamethasone

• High Dose Oxygen

• Therapeutic dose of Anticoagulant + Antibiotics



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Modes of Oxygen Therapy in Ward

• Nasal Canula ( 2 – 6 Litters/min )

• Simple Face Mask ( 6 – 10 Litters/min )

• NRBM ( 10 – 15 Lit/min )



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Modes of Oxygen Therapy in CCU

• BiPAP / NIV ( 25 – 40 Litters/min )

• HFNC ( 25 – 40 Litters/min )

• Ventilation ( 10 Lit/min )



Prof. Soumitra Ghosh

Rule of Three in COVID management

• Three Things to Remember

• Cat Like Observation is the Key

• Dexamethasone is the Game Changer

• Timely Escalation and De-escalation



Prof. Soumitra Ghosh

SAVE LIFE with Right Knowledge, Right Practice, and Courage

But, while Managing COVID Patients

Kindly Take Your Own Care
By COVID Appropriate Behaviour and Precautions

            

Prof. Soumitra Ghosh