Yesterday IAP MP and UP had jointly organised a very interesting webinar on Covid 19 preparedness with *Dr Dhiren Gupta, intensivist and Covid Expert, Dr Bakul J Parekh, National President IAP, and Dr Sujeet Singh(Director NCDC), Dr Kawita Bapat, Vice President FOGSI Elect* as experts panelists. It was widely appreciated and lasted for about 3.5 hours.
We are happy to share the salient features of the webinar.
1) If a patient needs to be admitted in hospital for delivery or life saving surgery where you donot have time for RT PCR test, you should consider doing a Rapid antigen test… if it is positive then the patient is having a Covid infection and should be immediately isolated after stabilising the patient or managing the emergency,but if the test comes back negative and patient is asymptomatic you need not repeat any test.
2) Patient treatment cannot be refused citing covid status - a separate room with precautions should be available in all nursing homes . And like I mentioned before, please do RT PCR test ... if it comes positive, stabilise the patient and treat them further in Covid facility. Ensure to sanitise the room properly after shifting the patient.
3) In patients with suggestive clinical features both antigen testing and RTPCR can be sent, especially in cases of emergencies... so as not to waste time if you need to do RT PCR ( if rapid antigen test negative) in strongly suspected Covid infection
4) Viremia per say doesn’t lead to mortality directly ( unless immunocompromised)but immune dysregulation like cytokine storm or MIS C with MOD is the actual reason for mortality in covid cases
6) Use steroids ( along with prophylactic Inj Clexan ) if respiratory discomfort, hypoxia and / or fever more than 102F on 6th day ( and rising )in a high risk patient ( age more than 60 yrs or comorbidities )
In patients with respiratory sign and symptoms first dose steroids should be given asap. It has been seen that delay of more than 6 hours can lead to high morbidity ( EVM protocol August 1st)
7) Drop in Spo2 by 4 after six minute walk is a very important sign to catch covid patients early . It unmasks the respiratory problems or “happy/silent hypoxia”
8) Do not perform this test if baseline Spo2 is already less than 94 percent
9) If patient is already on steroids then there is no importance of NLR ratio in monitoring
10) Escalation or deescalation of therapy shouldn’t only be based on clinical but also on oxygen level variation( SaO2 falling ) inflammatory markers( CRP ) and thrombotic markers (D DIMER ) . If CRP is rising more than 5 to 7 times or suddenly increasing then it is a surrogate marker of IL6 and take it as beginning of cytokine storm ( along with CF )This narrow window should not be missed and escalation of steroids , Inj Tocilizumab may be administered .only single dose of 8 mg/ kg is advisable . 2nd dose will not give extra benefit and on the contrary will increase chance of super infection. This is based on Mumbai experience ( in Other places practices are different )( please note that IL6 levels after Inj Tocilizumab will anyways keep increasing and should not be used for monitoring for next 24 to 48 hours ) .If d Dimer is increasing then give LMWH ( Inj Clexan) in therapeutic dose
11) Very early use of steroids ( in early phase of fever or mild disease) can lead to increase in viral replication causing more problems and increase in mortality by three times, as reported in New York data.
12) Steroids or stress can induce hyperglycaemia - Here you have to control sugar levels by giving Inj Insulin. Even Diabetic patients have to be given steroids ( because of its importance in management) and control sugar by insulin.
13) Pulmonary phase can be divided in two parts – early and late .Early is “L” type where elastase is low ( clinically picked up as Oxygen requirement increasing and increase in ground glassing ) Awake Proning is very important at this stage if it is not done already. Mechanical ventilation with intubation should be avoided .Also try to give maintainance fluids . During later ie H phase use conservative fluids ( Inj Lasix can be used ,keeping blood urea levels upto 60 to keep lungs dry) . Once patient slips into late pulmonary stage ie “ H” which is classical ARDS ( PF ratio less than 150 ) Here you may require intubation, at times tracheostomy and has bad prognosis.
14) Repeat CT scans should be avoided, but repeat Xray chest or USG may help in monitoring the progress.
15) Covid 19 is characterised by early setting of lung fibrosis . Use of early Anti fibrotic drugs can be thought of ( experimental stage ) But if you start steroids , LMWH, at right time and do respiratory excercises along with proning properly and frequently, it may yield better results.
16) CRP ( surrogate marker of IL 6 ) and Ddimer most important for monitoring after Inj Tocilizumab
17) Ferritin follows CRP with lag period and has a role if bicytopenia or HLH like picture , but anyways here also we give high dose steroids or pulse methyl prednisolone.
18) RT PCR or rapid antigen test should be done asap once Covid is suspected. Doctors Should not refrain from getting testing and should not depend on CT scan or radiology for diagnosis. If condition deteriorates or you need admission, it will be difficult to get a bed without the test results there by delaying the treatment leading to bad prognosis.
19) Based on experience it is seen that you have less chance of getting infected in COVID hospitals as compared to non covid hospitals as level of precautions taken are much higher. In non-covid hospitals we are less careful and tend to lower our guards.
20) Tab Ivermectin, Tab HCQ, Tab Azithromycin, Tab Doxycycline, have doubtful role therapeutically.
21) Tab HCQ may have some role in prevention or in pre exposure prophylaxis ... however that is debatable.
22) Tab Fevirapir was initially used in Japan but no role except for in mild cases and that too doubtful. Very difficult to swallow so many tabs and is hepatotoxic.
23) Inj Remdesivir may be useful when moderate infection that is when fever is persistent beyond 6 days or fever more than 102 with chills and have hypoxia. It may not change the course of the disease but may reduce few days of hospital stay. Further studies are required , and till then because of divided opinions and some usefulness without much serious side effects on liver which are very easily reversible, it may be used for a course of 5 days till further reports. It will be of no use after 10 days of onset of illness.
24) convalescence Plasma therapy may be helpful when virus is replicating, that is - between 7 to 10 days of illness and is generally not helpful if used at a later stage
25) Zn and VIT C may be useful to increase your immunity.
26) steam inhalation ( taking precautions to avoid burns) and gargles with Betadine or salt if done in a separate room and it may be useful .
27) Prevention is better than treating the disease which is so unpredictable. So *S*afe distancing, appropriate use of proper *M*ask and *S*anitisation ( SMS ) are very important and is declared as ( SOCIAL VACCINE ) . If everyone follows this religiously , without getting into arguments and not moving your mask up and down along with washing and sanitising your hands before touching your face, we can be protected effectively.
28) All patients with fever, cough and cold cannot be sent away in your daily practice but if you see them after proper triaging while taking care of “SMS” in well ventilated areas without crowding... you can continue practising as a new normal ...
Telecommunication, calling patient by appointments, taking them in your waiting room with proper distancing after hand sanitisation and masking in a well ventilated properly designed room, HCW wearing masks , collecting money by card or by no touch technique, as advised and doing tests as and when required.
Stay safe, stay alert and stay healthy!
Dr CP Bansal
Dr Vineet Saxena
ટિપ્પણીઓ નથી:
ટિપ્પણી પોસ્ટ કરો