Management of covid 19

Management of covid 19

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  MANAGEMENT OF COVID-19 PRESENTER: DR.PRADEEP MODERATOR:DR.HARISH SIR
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  MANAGEMENT OF COVID-19 IN COMMUNITYAND NON- ICU SETTINGS
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  COMMUNITY MANAGEMENT: All childrensuspected of having COVID-19 exposure or infection with mild symptoms should be advised quarantine in COVID-19 isolation centres , if available or they may be advised home quarantine Home quarantine : Patients should preferably stay in well ventilated single rooms with attached bathrooms. If another person other than care taker of a small child needs to share the room, he should maintain a distance of one metre at all times.  He/she should stay away from older adults, pregnant ladies, other children and patients with comorbidities.
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  They should practicestrict personal hygiene, including hand hygiene and wearing of masks. Masks used by patients /close contacts during home care should be disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep burial. Family members cleaning the room or handling soiled linen should wear disposable gloves and wash hands with soap and water after removing gloves. Patients should seek medical advice if any COVID-19 infection symptoms appear including fever, cough, diarrhoea, vomiting or breathlessness and all close contacts in such a situation should be home quarantined (for 14 days).
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  HOSPITAL MANAGEMENT:  Inthe COVID-19 isolation areas, the patient should be triaged for the severity of the infection Triage questions : 1. Has someone in your close family returned from a foreign country? Yes/No 2. Is the patient under home quarantine as advised by the local health authority? Yes/No 3. Have you or someone in your family come in close contact with a confirmed COVID- 19 patient in the last 14 days? Yes/No 4. Do you have fever? Yes/No 5. Do you have cough /sore throat? Yes/No 6. Do you feel shortness of breath? Yes/No
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  CLINICAL CATEGORISATION FOR PLANNINGTHERAPY: All children with suspected COVID-19 infection should be categorized into three categories. Category A (Mild symptomatic patients) :Mild sore throat, fever, cough, rhinorrhea, vomiting. Category B (moderate symptoms / patient with comorbidities) : Fever, severe sore increasing cough. Category A symptoms in children with chronic heart, kidney, lung, neurological or liver disease and children on long term steroids, congenital or acquired immunosuppression. Category C (severe and critical disease) : Altered sensorium, respiratory distress, SpO2 < breathlessness, cyanosis, inability to feed, seizures, hypotension.
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  SEVERITY CATEGORY ACATEGORY B CLINICAL CRITERIA ▪ Fever ▪ Sore throat ▪ Rhinorrhea ▪ Cough ▪ Diarrhoea ▪ Vomiting ▪ Pain abdomen ❑ Fast breathing (age-based criteria) ▪ <2 months: ≥60/min ▪ 2-12 months: ≥50/min ▪ 1-5 years: ≥40/min ▪ >5 years: ≥30/min ❑ SpO2 90-94% WHAT TO DO? HOME ISOLATION ADMIT IN COVID-WARD INVESTIGATIONS ▪ None ▪ If there is high grade fever for >3-4 days – investigate for – CBC, CRP, Urine R/E, Blood C&S, C&S, CXR ▪ At admission: CBC,SE,LFT,RFT, CRP, PT,INR,APTT, D-dimer, blood culture, CXR (Dengue/MP/Weil Felix etc clinically directed) WHEN TO REPEAT Clinically directed ▪ Repeat after 48-72 hours, as per clinical course TREATMENT. ▪ Paracetamol 10-15 mg/kg ▪ Ensure adequate hydration ▪ Physical distancing, Mask, Strict hand hygiene ▪ ORS, Zinc, if child has diarrhoea ▪ Reassurance and counsel about danger signs ▪ No Antibiotics for 3 days of high fever, start Amox/Amoxclav /Azithromycin if bacterial inf suspected ▪ Paracetamol 10-15 mg/kg, 4-6 hourly for fever ▪ Oral feeding or IV fluids ▪ Correct dehydration, if present ▪ Oxygen (nasal prongs / NRM) if SpO2 <94% or increasing distress ▪ Awake proning (if possible, 2 hourly position change) ▪ Antibiotic (Amox-clav +/- Azithromycin ) ▪ Steroids.
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  WHAT TO MONITOR? EVERY2-4 hourly. ▪ HR,BP,CFT ▪ RR,SpO2 ▪ Temperature ▪ Oral intake ,U/O and hydration status ▪ Sensorium
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  RED FLAG SIGNS: Persistent fever (>102 F) ≥4-5 days Rapid breathing, cyanosis or SpO2 <94% Poor oral intake, pain abdomen, loose stools Lethargy/irritability, rash Decreased U/O, dry mucosa, sunken eyes
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  INFECTION PREVENTION & CONTROLIN COVID-19 SCENARIO Infection prevention and control (IPC) measures are of paramount importance in managing patients with COVID-19 infection.  Encourage all patients to wear masks, and advice patients to keep 1-metre distance between them.  Use PPE while entering the room with a triple layer mask, gown and goggles and remove when leaving.  Aerosol precautions should be taken while doing aerosol-generating procedures.  Disinfection of equipment, cleaning of patient’s surrounding and safe disposal of waste are also part of IPC measures. Hand hygiene.
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  CRITICAL CARE MANAGEMENT OF COVID-19
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  INDICATIONS OF PICU ADMISSION: Requirement for significant respiratory support that cannot be provided elsewhere such as non-invasive or invasive ventilation. This may be due to hypoxia, hypercarbia or increased work of breathing.  Requirement for cardiovascular support including multiple fluid boluses or inotropes. This may be because of hyperinflammatory syndrome, myocarditis or significant co-infections.  Deterioration of neurological status. This may be due to direct COVID-19 related neurological complications (e.g. seizures, encephalopathy) or related to respiratory complications such as hypoxia.  Any child considered to be at risk of further deterioration requiring continuous or close monitoring requiring higher nurse: patient ratios.
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  HFNC OXYGEN THERAPY: Children with hypoxia (oxygen saturation <92%) should receive supplemental oxygen.  In the children who require higher concentration of supplemental oxygen, heated and humidified oxygen with HFNC may be well tolerated and may reduce the need for invasive ventilation.  It is probably safe to use HFNC for children with mild-moderate disease severity, especially if the HCW uses full PPE and children are nursed in cubicles.  Routine monitoring of heart rate, respiratory rate, fractional inspired oxygen (FiO2 ), work of breathing and comfort levels are essential to assess the effectiveness of HFNC therapy.
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  NON-INVASIVE VENTILLATION:  NIVusing a full face or oro nasal mask interface can be tried in selected patients based on local experience.  Bubble CPAP may especially be a useful mode of support in young infants.  Intubation must be recommended if there is no improvement in oxygenation (target SpO2 92 - 97% and FiO2 < 0.6) within 60-90 minutes of initiating NIV
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  INVASIVE VENTILATION: Strategies tominimise HCW protection from aerosols during invasive mechanical ventilation of suspected or confirmed COVID-19, may include: The use of appropriate full PPE Inline suction Minimise circuit disconnection Temporary clamping of endotracheal tube (ETT) when disconnection is essential Passive humidification with a heat moisture exchanger (HME) filter rather than active humidification, viral filter in the expiratory limb of the ventilator circuit Pre-attached viral filters in bagging circuits for use in emergencies.
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  Initial setting shouldaim to achieve:  Tidal volumes between 4 to 8 mL/kg of ideal body weight,  PEEP between 6 to 10 cm H2 O and  Plateau pressure under 28 cm H2 O.  Permissive hypoxia (SpO2 88-92% if PEEP >10, or else 92-97% if PEEP <10cm H2O )and permissive hypercapnia(if pH<7.15) are acceptable to achieve optimal lung protection.  Prone ventilation can improve oxygenation and lung homogeneity in children. children.  It is likely that pediatric critical care units have had already experience with proning and have set policies and procedure which would help them to adapt adapt to it.
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  OTHER SUPPORTIVE CARE: Judiciousfluid management is the key to the care of any critically ill child. Following restoration of intravascular volume a restriction of daily allowance 70-80% of calculated fluid requirement using Holliday-Segar formula is a good starting point. Enteral feeding should be commenced at the earliest possible opportunity, if to do so. Empirical antibiotics are justified until a diagnosis is established and/or co- infections are excluded even if the SARS-CoV-2 PCR is positive.
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  CASE DEFINITION OFMIS-C:  Younger than 21 years, with fever >3days AND,  Elevated markers of inflammation (ESR, CRP, PROCALCITONIN) AND,  No other cause of microbial inflammation (bacterial sepsis) AND,  Evidence of COVID-19 (RT-PCR, antigen test) or likely contact with patients with COVID-19 AND, AND ANY 2 OF THESE:  Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands, feet).  Hypotension or shock,  Evidence of coagulopathy,  Acute GI problems (diarrhoea, vomiting, pain abdomen),  Features of myocardial dysfunction or coronary abnormalities (elevated Troponin).
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  NEONATAL COVID-19
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  INTRODUCTION:  The generalinformation from the literature so far indicates that neonatal COVID-19 infection may be uncommon.  It is generally acquired through postnatal transmission rather than vertical transmission.  Newborn infants with COVID-19 infection exhibit either no symptoms or mild respiratory illness.  The higher percentage of fetal hemoglobin in newborn infants may be protective over SARS-CoV-2
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  DEFINITION: SARS-CoV-2 infected neonateswere defined as those with a positive SARS-CoV-2 quantitative RT-PCR test in nasopharyngeal swab within 28 days of birth. The perinatal transmission was defined as positive nasopharyngeal RT-PCR in a neonate in the first 72 hours after birth. This included intrauterine and intrapartum transmission. Testing was avoided in the first 12 hours to minimize false positives due to superficial colonization. The horizontal transmission was considered in a neonate with negative RT-PCR within the first 72 hours who subsequently tested positive any time after 72 hours of birth irrespective of the mother's SARS-CoV-2 status.
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  MATERNAL TRANSMISSION TO NEWBORN: 3Potential mechanisms of maternal transfer of SARC COV-2 to the infant: 1. INTRAUTERINE TRANSMISSION through transplancental hematogenous spread or viral particles in amniotic fluid that are ingested or inhaled by the fetus. This mode appears less likely but there are are reports suggesting that this is possible. 2. INTRAPARTUM TRANSMISSION after exposure to maternal infected secretions or feces around the time of birth. 3. POSTPARTUM TRANSMISSION from an infected mother, family member, or health care worker (probably the most likely mode of transmission). Transmission from infected mother is more likely from respiratory secretions and less likely from breast milk.
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  DIAGNOSIS: Diagnosis of anewborn infant born to a suspected or COVID positive mother is imperative. RT-PCR testing of nose and throat swab for detection of SARS-CoV-2 nucleic acid has been recommended as the confirmatory test for COVID19. Other alternative sample could be endotracheal aspirate. Whom to test: All newborn infants who have any one of the following: 1) History of exposure to COVID-19 positive adult (irrespective of symptoms), mother had COVID-19 infection within 14 days before birth, history of contact with COVID-19 positive persons (including mother, family members in the same household or direct healthcare provider) in the postnatal period. 2) Irrespective of history of exposure: Presenting with pneumonia or severe acute respiratory infection (SARI) that require hospitalization, with onset at more than 48-72 hours of age, unless there is another underlying illness that completely explains the respiratory signs and symptoms
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  When to dothe test a) At birth (if mother had COVID-19) or at detection of the history of contact with COVID- 19 positive person (postnatal exposure) b) If a sample is not obtained at birth due to logistic reasons, it should be obtained as soon soon as possible. When to do repeat test? If the first test is negative, a repeat test should be done after 5-14 days of birth/exposure. However, the test should be done immediately, if new symptoms such as respiratory distress, lethargy, seizures, apnea, refusal to feed, diarrhoea appear.
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  ANTENATAL MANAGEMENT: Pregnant womenshould follow the same recommendations as nonpregnant adults for avoiding exposure to the virus like social distancing, hand hygiene, disinfecting surfaces and wearing a mask in public.  Pregnant women with confirmed COVID-19 should be managed with supportive care recommended for non-pregnant adults. Currently recommended management includes: oxygen therapy/respiratory support for treatment of hypoxemic respiratory failure, fluid therapy, antibiotics and management of shock.1 All COVID-19 positive pregnant women should be referred to designated COVID care facility. Antenatal steroids have proven benefits in neonatal mortality and morbidity, in pregnant women between 24+0 and 33+6 weeks of gestation with suspected or confirmed COVID-19.16 For pregnant women between 34+0 and 36+6 weeks of gestation, these decisions may need to be individualized
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  DELIVERY ROOM MANAGEMENT: Themode of delivery and anesthesia is best decided as per maternal and fetal indications. The optimal location for neonatal stabilization and resuscitation could be in an adjacent room or the same place at least 6 feet or 2 meters away from the mother with a physical barrier. Neonatal resuscitation should be performed according to the Neonatal Resuscitation India. Following key aspects must be kept in mind during resuscitation During initial steps: Routine neonatal care and the initial steps of neonatal resuscitation are unlikely to be aerosol generating, however, suction of the airways is an aerosol generating procedure and should not be performed routinely for clear or meconium-stained amniotic fluid. Transport to NICU: Closed incubator transfer should be used to transfer newborns
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  SHOULD WE CONTINUEDELAYED CORD CLAMP & SKIN TO SKIN CONTACT PRACTICED ? Delayed cord clamping and skin-to-skin contact can be practiced. WHO recommends skin to skin care and rooming-in. There are problems with separation approach, as separation limits opportunities for parent teaching, disrupts breastfeeding and may have negative impacts on mother-newborn bonding. Rooming-in during hospitalization helps mother and family to learn infection prevention practices.
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  CAN THE INFANTBREASTFED ? The possibility of the vertical transmission of SARS- CoV-2 through breast milk could not be confirmed. The Indian team (FOGSI, NNF and IAP) recommends rooming in and breastfeeding with strict precautionary measures. If an infected mother chooses not to nurse her newborn, she may express breastmilk after appropriate hand hygiene, and fed by unaffected caregivers. Finally, with the available current evidence, benefits of breastfeeding outweigh the risks of passing infection from mother to infant.
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  WHEN THE INFANTIS READY FOR HOSPITAL DISCHARGE? 1. IF INFANTS SARS COV-2 TESTING IS POSITIVE, but the infant has no signs of COVID-19.plan for frequent outpatient follow up for 14 days after birth. During this period take percuations to prevent spread from infant to caregivers. 2. IN MOST CASES THE INFANTS SARS COVID-2 TESTING WILL BE NEGATIVE where infant should be discharged and measures to be taken by mother by wearing mask and hand hygiene when directly caring for the infant until: She has been afebrile for 24 hrs without use of antipyretics. At least 14 days have passed since her symptoms first appeared. Symptoms have improved. 3. IF THE INFANT CANNOT BE TESTED, then treat the infant as virus positive for 14 day period of observation.
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  RECENT STUDY: Outcomes ofNeonates Born to Mothers with Coronavirus Disease 2019 (COVID-19) – National Neonatology Forum (NNF) India COVID-19 Registry. By Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Published @ March 20,2021. In this prospective cohort study, Limited evidence exists on perinatal transmission and outcomes of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in neonates.
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  STUDY INCLUDES: Neonates bornto women with SARS-CoV-2 infection within two weeks prior to or two days after delivery and neonates with confirmed SARS-CoV-2 infection within 28 days of life were eligible for enrolment in the study. All neonates were monitored for clinical symptoms for the first seven days after birth and for as long as the mother was admitted to the hospital.
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  RESULT: Total cases receivedby COVID-19 REGISTRY= 1733 cases. 1649 (95%) government hosp. 82 (5%) private hosp. Out of 1733 cases 22 cases were excluded as both mother and neonate were negative for COVID-19. Remaining 1711 ( 95% were asymptomatic, 4% symptomatic, 1% were critically ill.)
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  Total intramural cases-1589. Out of which test not done in – 259. Remaining neonates tested -1330. Total positive cases – 189. Positive within 72 hours (perinatal transmission) – 168. Positive >72 hours (horizontal transmission) -21.
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  The risk oftransmission was not associated with the mode of delivery or type of feeding. The risk of transmission of SARS-CoV-2 from mother to neonate was marginally higher if the baby was roomed-in with the mother. The prematurity rate, which was higher in SARS-CoV-2 positive group. SARS-CoV-2 positive neonates were five times more likely to be symptomatic and twice more likely to need resuscitation. They had significantly higher probability of having sepsis and septic shock. SARS-CoV-2 positive neonates were more likely to have abnormal radiological findings and need respiratory support. They were also more likely to have received surfactant, steroids, and inotropes.
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  DISCUSSION: This study highlightsthat SARS-CoV-2 positive neonates are more likely to be symptomatic, more likely to have respiratory symptoms, and other neonatal morbidities. However, the mortality is not increased significantly. Common symptoms reported include respiratory distress, fever, and those related to gastrointestinal illness. Most of the infected neonates were not reported to need any respiratory support and had a good outcome after a median duration of hospitalization of 10 days.  Another important finding in our cohort is that SARS-CoV-2 infected neonates were significantly more likely to need resuscitation, be symptomatic, need NICU admission, have abnormal chest X-rays, and need respiratory support.
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  THANK YOU ....