Management of covid19

Management of covid19

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  MANAGEMENT OF COVID19 By Dr.Md. Razi Ahmad, MD (Medicine). Assistant Professor, GTCH, Patna.
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  OBJECTIVES TO LEARN Definedthe triages Evaluation of systemic involvement Therapeutic Management ICU Management Prognosis Re-infection
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  HOW TO DEFINEDTRIAGES Uncomplicated illness Severe Pneumonia ARDS Septic Shock Mild Pneumonia
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  UNCOMPLICATED ILLNESS Patients withuncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache. The elderly and immunosuppressed may present with atypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of breath.
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  MILD PNEUMONIA  Patientwith pneumonia and no signs of severe pneumonia.  Child with non-severe pneumonia has cough or difficulty in breathing (Dyspnoea) / fast breathing (Tachypnoea),  breaths/min <2 months, ≥60  2–11 months, ≥50  1–5 years, ≥40 and no signs of severe pneumonia
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  SEVERE PNEUMONIA  Adolescentor adult: fever or suspected respiratory infection, plus one of the following; Respiratory rate >30 breaths/min, & severe respiratory distress, SpO2 <90% on room air  Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 <90%;  Severe respiratory distress (e.g. grunting, chest in- drawing);  Signs of pneumonia with any of the following danger signs: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions.  Other signs of pneumonia may be present: chest indrawing, fast breathing (in breaths/min): <2 months ≥60; 2–11 months ≥50; 1–5 years ≥40.  The diagnosis is clinical; chest imaging can exclude complications.
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  ACUTE RESPIRATORY DISTRESSSYNDROME  Onset: New or worsening respiratory symptoms within one week of known clinical insult.  Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.  Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of edema if no risk factor present.
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  CLASSIFICATION OF ARDS Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated) Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5  Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated) Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3  Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cm H2O, or non-ventilated) Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3  When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)  Oxygenation (children; note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)  Bilevel NIV or CPAP ≥5 cm H2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤264
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  SEPTIC SHOCK  Adults:Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level < 2 mmol/L .  Children: Any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following:  Altered mental state  Bradycardia or tachycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children);  Prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash;
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  EVALUATION OF SYSTEMICINVOLVEMENT 1. History of co-morbidity: (HTN, DM, Malignancies etc with their treatment) 2. Coagulation profile 3. Echocardiography 4. Secondary infection (CBC, Blood Culture & Sensitivity) 5. BSL 6. Kidney Function test (Including Electrolytes) 7. Pregnancy or elderly aged
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  THERAPEUTIC MANAGEMENT As itis well known there is no definite treatment available so treatment should be on the base of other acute respiratory infection guideline, including prevention of outbreak and safety of healthcare professional. I. Prevention of infection II. Oxygen supplementation III. NIV / Invasive ventilation IV. Medication
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  HOW TO IMPLEMENTINFECTION PREVENTION AND CONTROL MEASURES FOR PATIENTS WITH SUSPECTED OR CONFIRMED COVID - 19 INFECTION 1. At Triage  Give suspect patient a triple layer surgical mask and direct patient to separate area, an isolation room if available.  Keep at least 1meter distance between suspected patients and other patients.  Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for others.  Perform hand hygiene after contact with respiratory secretions.
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  2. APPLY DROPLETPRECAUTION  Droplet precautions prevent large droplet transmission of respiratory viruses. Use a triple layer surgical mask if working within 1-2 meters of the patient.  Place patients in single rooms, or group together those with the same etiological diagnosis.  If an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors, with a spatial separation.  When providing care in close contact with a patient with respiratory symptoms (e.g. coughing or sneezing), use eye protection (face-mask or goggles), because sprays of secretions may occur.  Limit patient movement within the institution and ensure that patients wear triple layer surgical masks when outside their rooms.
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  3. APPLY CONTACTPRECAUTION  Droplet and contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces). Use PPE (triple layer surgical mask, eye protection, gloves and gown) when entering room and remove PPE when leaving.  If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers).  If equipment needs to be shared among patients, clean and disinfect between each patient use.  Ensure that health care workers refrain from touching their eyes, nose, and mouth with potentially contaminated gloved or ungloved hands.  Avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Ensure adequate room ventilation. Avoid movement of patients or transport. Perform hand hygiene.
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  4. APPLY AIRBORNEPRECAUTION  Ensure that healthcare workers performing aerosol-generating procedures (i.e. open suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation) use PPE, including gloves, long-sleeved gowns, eye protection, and fit- tested particulate respirators (N95).  The scheduled fit test should not be confused with user seal check before each use.  Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation.  Avoid the presence of unnecessary individuals in the room. Care for the patient in the same type of room after mechanical ventilation commences .
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  5. EARLY SUPPORTIVETHERAPY AND OXYGENATION  Supplemental oxygen patients with SARI and respiratory distress, hypoxaemia, or shock: 5 L/min and titrate flow rates to reach target SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-95 % in pregnant patients.  Children with emergency signs: Obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions, oxygen therapy during resuscitation to target SpO2 ≥94%; otherwise, the target SpO2 is ≥90%.  All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning oxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal cannula, simple face mask, and mask with reservoir bag).  Use contact precautions when handling contaminated oxygen interfaces of patients with COVID – 19.  Use conservative fluid management in patients with SARI when there is no evidence of shock.
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  CONT….  Give empiricantimicrobials to treat all likely pathogens causing SARI. Give antimicrobials within one hour of initial patient assessment for patients with sepsis: Although the patient may be suspected to have COVID - 19, Administer appropriate empiric antimicrobials within ONE hour of identification of sepsis.  Empirical therapy includes a neuraminidase inhibitor for treatment of influenza when there is local circulation or other risk factors, including travel history or exposure to animal influenza viruses  Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of clinical trials unless they are indicated for another reason.  Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and apply supportive care interventions.  Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and determine which chronic therapies should be continued and which therapies should be
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  6. HYPOXEMIC RESPIRATORYFAILURE AND ARDS  Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy.  High – flow nasal catheter oxygenation or non – invasive mechanical ventilation: when oxygen is delivered via a face mask with reservoir bag (flow rates of 10-15 L/min, which is typically the minimum flow required to maintain bag inflation; FiO2 0.60-0.95).  If conditions do not improve or even get worse within a short time (1 – 2 hours), tracheal intubation and invasive mechanical ventilation should be used in a timely manner.  Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.  Implement mechanical ventilation using lower tidal volumes (4–8 ml/kg predicted body weight, PBW) and lower inspiratory pressures (plateau pressure <30 cmH2O).  Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.
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  7. MANAGEMENT OFSEPTIC SHOCK  Standard care includes early recognition and the following treatments within 1 hour of recognition: antimicrobial therapy and fluid loading and vasopressors for hypotension. The use of central venous and arterial catheters should be based on resource availability and individual patient needs.  In resuscitation from septic shock in adults, give at least 30 ml/kg of isotonic crystalloid in adults in the first 3 hours. In resuscitation from septic shock in children in well-resourced settings, give 20 ml/kg as a rapid bolus and up to 40-60 ml/kg in the first 1 hr. Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.  Fluid resuscitation may lead to volume overload, including respiratory failure. If there is no response to fluid loading and signs of volume overload then reduce or discontinue fluid administration.
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  CONT…  Crystalloids includenormal saline and Ringer’s lactate. Determine need for additional fluid boluses (250-1000 ml in adults or 10-20 ml/kg in children) based on clinical response and improvement of perfusion targets. Perfusion targets include MAP (>65 mmHg or age-appropriate targets in children), urine output (>0.5 ml/kg/hr in adults, 1 ml/kg/hr in children), level of consciousness, and lactate.  Administer vasopressors when shock persists during or after fluid resuscitation. The initial blood pressure target is MAP ≥65 mmHg in adults and age-appropriate targets in children.  If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein and closely monitor for signs of extravasation and local tissue necrosis.  If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors, consider an inotrope such as dobutamine.
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  8. OTHER THERAPEUTICMEASURES  For patients with progressive deterioration of oxygenation indicators, rapid worsening on imaging and excessive activation of the body’s inflammatory response, glucocorticoids can be used for a short period of time (3 to 5 days). It is recommended that dose should not exceed the equivalent of methylprednisolone 1 – 2mg/kg/day. Note that a larger dose of glucocorticoid will delay the removal of coronavirus due to immunosuppressive effects. For pregnant severe and critical cases, pregnancy should be preferably terminated. Consultations with obstetric, neonatal, and intensive care specialists (depending on the condition of the mother) are essential. Patients often suffer from anxiety and fear and they should be supported by psychological counselling.
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  9. PREVENTION OFCOMPLICATION Anticipated outcome Interventions Reduce days of invasive mechanical ventilation Use weaning protocols that include daily assessment for readiness to breathe spontaneously . Minimize continuous or intermittent sedation, Reduce incidence of ventilator associated pneumonia Oral intubation is preferable to nasal intubation . Keep patient in semi-recumbent position (head of bed elevation 30-45º). Use a closed suctioning system. Change heat moisture exchanger when it malfunctions, when soiled, or every 5-7days Reduce incidence of venous thromboembolism Use pharmacological prophylaxis (LMWH or heparin 5000 units subcutaneously twice daily) in adolescents and adults. For those with contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices). Reduce incidence of catheter related bloodstream Use a checklist with completion verified by a real-time observer as reminder of each step needed for sterile
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  CONT…. Anticipated outcome Interventions Reduce incidence of pressureulcers Turn patient every two hourly Reduce incidence of stress ulcers and gastrointestinal bleeding Give early enteral nutrition (within 24–48 hours of admission) Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI bleeding. Risk factors for gastrointestinal bleeding include mechanical ventilation for ≥48 hours, coagulopathy, renal replacement therapy, liver disease, multiple co-morbidities, and higher organ failure score Reduce incidence of ICU-related weakness Actively mobilize the patient early in the course of illness when safe to do so
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  SPECIFIC COVID -19 TREATMENTS AND CLINICAL RESEARCH  There is no current evidence from RCTs to recommend any specific treatment for suspected or confirmed patients with COVID - 19. No specific anti–virals are recommended for treatment of COVID – 19 due to lack of adequate evidence from literature. The use of Lopinavir/ Ritonavir in PEP regimens for HIV (4 weeks) is also associated with significant adverse events which many a times leads to discontinuation of therapy. In light of the above, Lopinavir/ Ritonavir should ONLY be used with proper informed expressed consent on a case to case basis for severe cases
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  ADMINISTRATION OF LOPINAVIR/RITONAVIR  Lopinavir/ Ritonavir to be considered in Laboratory confirmed cases of COVID – 19 when the following criteria are met: Symptomatic patients with any of the following: I. Hypoxia II. Hypotension III. new onset organ dysfunction (one or more)  Increase in creatinine by 50% from baseline, GFR reduction by >25% from baseline or urine output of <0.5 ml/kg for 6 hours.  Reduction of GCS by 2 or more  Any other organ dysfunction IV. High Risk Groups: Age> 60 yrs, Diabetes Mellitus, Renal Failure, Chronic Lung disease Immuno – compromised persons. V. Dose: Lopinavir/ Ritonavir (200 mg/ 50 mg) – 2 tablets twice daily For patients unable to take medications by mouth: Lopinavir 400mg/ Ritonavir 100 mg – 5ml suspension twice daily. VI. Duration: 14 days or for 7 days after becoming asymptomatic.
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  HCQ ANTI MALARIAL Chloroquine: chloroquine slowed the progression of pneumonia and accelerated SARS-CoV-2 clearance and recovery in >100 patients with COVID-19, but results have not been published in the peer-reviewed literature and caution is advised in interpreting these findings in-vitro antiviral effects reported for both SARS- CoV and SARS-CoV-2. but no peer-reviewed, published safety data available for SARS-CoV-2, but concerns include the possibility of QT prolongation.  Hydroxychloroquine: Reduced SARS-CoV-2 load in the nasopharynx of patients with COVID-19, especially when combined with azithromycin;more potent than chloroquine in inhibiting SARS-CoV-2 in vitro, but no peer-reviewed, published safety data available for SARS-CoV-2, but concerns include the possibility of QT prolongation.
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  INTRAVENOUS IMMUNOGLOBULIN (IMMUNOTHERAPY) Phase 1 trial of human polyclonal immunoglobulin G (SAB- 301) in healthy participants; SAB-301 found to be safe and well tolerated;  study of human polyclonal immunoglobulin G (SAB-300) in a mouse model of MERS-CoV SAB-300 reduced viral lung titres near or below the limit of detection in mice infected with MERS-CoV  No peer-reviewed, published safety data available for the various types of interferon (alfa and beta) for SARS-CoV-2, but generally well tolerated Tocilizumab (monoclonal antibody against interleukin-6)  Licensed for cytokine release syndrome; hypothesised to work against cytokine storm with raised ferritin and interleukin-6 levels due to SARS-CoV-2  No peer-reviewed, published efficacy & afety data available for SARS-CoV-2
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  CONVALESCENT PLASMA (IMMUNOTHERAPY) Meta-analysisof 27 studies of treatment in patients with SARS-CoV infection;use has been protocolised for MERS-CoV2; Might reduce mortality in severe acute respiratory infections due to SARS-CoV and influenza; No peer-reviewed, published safety data available for SARS-CoV-2,  Uncontrolled case series of 5 patients with SARS-CoV- 2 associated with reduction in viral load and improvement in fever, oxygenation, and chest imaging in a case series, but study limited by small sample size, multiple possible confounders, and absence of controls but studies of SARS-CoV have not reported serious adverse events
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  PSYCHOLOGICAL SUPPORT  Individualsmay experience distress from quarantine, travel restrictions, side effects of treatment or fear of the infection itself. To address these concerns, the National Health Commission of China published a national guideline for psychological crisis intervention on 27 January 2020
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  PROGNOSIS
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  PROGNOSIS CONT…  Theseverity of COVID-19 varies. The disease may take a mild course with few or no symptoms, resembling other common upper respiratory diseases such as the common cold. Mild cases typically recover within two weeks, while those with severe or critical diseases may take three to six weeks to recover. Among those who have died, the time from symptom onset to death has ranged from two to eight weeks  Children are susceptible to the disease, but are likely to have milder symptoms and a lower chance of severe disease than adults; in those younger than 50 years, the risk of death is less than 0.5%, while in those older than 70 it is more than 8%  In those most severely affected, COVID-19 may rapidly progress to acute respiratory distress syndrome (ARDS) causing respiratory failure, septic shock or multi-organ failure.[189][190] Complications associated with COVID-19 include sepsis, abnormal clotting and damage to the heart, kidneys and liver. Clotting abnormalities, specifically an increase in prothrombin time, have been described in 6% of those admitted to hospital with COVID-19, while abnormal kidney function is seen in 4% of this group.
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  RE-INFECTION  As ofMarch 2020, it was unknown if past infection provides effective and long- term immunity in people who recover from the disease. Immunity is seen as likely, based on the behaviour of other coronaviruses, but cases in which recovery from COVID-19 have been followed by positive tests for coronavirus at a later date have been reported. These cases are believed to be worsening of a lingering infection rather than re-infection