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Covid 19 infection and management

Definition, disease transmission,sign and symptoms, pathophysiology,treatment,complication

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Covid 19 infection and management

  1. 1. Ms.Parisha Chaudhari Assistant Professor Maniba Bhula Nursing College Uka Tarsadia University Bardoli. COVID 19 Infection and Management
  2. 2. COVID 19 Infection
  3. 3. What do we know about COVID- 19?  Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus.
  4. 4. HOW IT SPREADS ?
  5. 5. What are the symptoms?
  6. 6. • Fever, cough, sore throat, nasal congestion, malaise, headache Uncomplicated illness • Patient with pneumonia and no signs of severe pneumonia. • Child have cough or difficulty in breathing/ fast breathing: (fast breathing - in breaths/min): • <2 months, ≥60; • 2–11 months, ≥50; • 1– 5 years, ≥40 and no signs of severe pneumonia Mild pneumonia
  7. 7. • Adolescent or 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 : • SpO2 <90%; severe respiratory distress. • 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.
  8. 8. • 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 oedema if no risk factor present. Acute Respiratory Distress Syndrome
  9. 9. • Adults: life-threatening organ dysfunction include: • altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia. • Children: suspected or proven infection and ≥2 SIRS criteria, of which one must be abnormal temperature or white blood cell count Sepsis
  10. 10. • 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; increased lactate; oliguria; hyperthermia or hypothermia Septic Shock
  11. 11. Diagnostic Test
  12. 12.  Serological tests  Nucleic acid amplification tests  CBC count  Polymerase chain reaction  Isothermal amplification assays  Antigen tests  Lung computed tomography  Chest X ray  CT scan  Chest ultrasound
  13. 13. Polymerase chain reaction
  14. 14. Prophylaxis  Vitamin C 500 mg BID Quercetin 250-500 mg BID Melatonin 0.3mg to 2 mg Zinc 75- 100 mg/day Vitamin D3 1000- 4000 u/day
  15. 15. Symptomatic patients (at home):  Vitamin C 500 mg BID and Quercetin 250-500 mg BID  Zinc 75-100 mg/day  Melatonin 6-12 mg at night (the optimal dose is unknown)  Vitamin D3 1000-4000 u/day  Optional: ASA (aspirin) 81 -325 mg/day  Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days  Optional: In highly symptomatic patients, monitoring with home pulse oximetry is recommended
  16. 16. Mildly Symptomatic patients:  Vitamin C 500mg q 6 hourly and Quercetin 250-500 mg BID (if available)  Zinc 75-100 mg/day  Melatonin 6-12 mg at night (the optimal dose is unknown)  Vitamin D3 1000-4000 u/day  Enoxaparin 60 mg daily  Methylprednisolone 40 mg daily; increase to 40mg q 12 hourly in patients with progressive symptoms and increasing CRP  Famotidine 40mg daily (20mg in renal impairment)
  17. 17. Cont…  Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days  Optional: Remdesivir, if available  Nasal cannula 2L /min if required (max 4 L/min; consider early t/f to ICU for escalation of care).  Avoid Nebulization and Respiratory treatments. Use “Spinhaler” or Metered Dose Inhaler and spacer if required.  Avoid non-invasive ventilation  T/f EARLY to the ICU for increasing respiratory signs/symptoms and arterial desaturation.
  18. 18. Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: admit to ICU):  Essential Treatment (dampening the STORM) 1. Methylprednisolone 80 mg loading dose then 40mg q 12 hourly for at least 7 days and until transferred out of ICU. In patients with an increasing CRP or worsening clinical status increase the dose to 80mg q 12 hourly, then titrate down as appropriate. 2. Ascorbic acid (Vitamin C) 3g IV 6 hourly for at least 7 days and/or until transferred out of ICU.
  19. 19. 3. Full anticoagulation:  Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg/ kg s/c q 12 hourly .  Heparin is suggested with CrCl (creatinine clearance) < 15 ml/min. Alternative approach: Half-dose rTPA (alteplase): 25mg of tPA (tissue plasminogen activator) over 2 hours followed by a 25mg tPA infusion administered over the subsequent 22 hours, with a dose not to exceed 0.9 mg/kg followed by full anticoagulation.
  20. 20. Additional Treatment Components (the Full Monty) 4. Melatonin 6-12 mg at night (the optimal dose is unknown). 5. Famotidine 40mg daily (20mg in renal impairment) 6. Vitamin D 400u PO daily 7. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. 8. Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days (has immunomodulating properties including downregulating IL-6; in addition, Rx of concomitant bacterial pneumonia).
  21. 21. 9. Optional: Atorvastatin 40-80 mg/day. Of theoretical but unproven benefit.  Statins – it reduce mortality in the hyper- inflammatory ARDS phenotype. 10. Broad-spectrum antibiotics  If superadded bacterial pneumonia is suspected based on procalcitonin levels and resp.
  22. 22. Cont… 11. Maintain EUVOLEMIA  Rehydration with 500 ml boluses of Lactate Ringers may be warranted, ideally guided by noninvasive hemodynamic monitoring.  Diuretics should be avoided unless the patient has obvious intravascular volume overload.  Avoid hypovolemia. 12. Early norepinephrine for hypotension.
  23. 23. Cont… 13. Escalation of respiratory support (steps);  Accept “permissive hypoxemia” (keep O2 Saturation > 84%);  Follow venous lactate and Central Venous O2 saturations in patents with low arterial O2 saturations  N/C 1-6 L/min  High Flow Nasal cannula (HFNC) up to 60-80 L/min  Trial of inhaled Flolan (epoprostenol)  Attempt proning (cooperative repositioning-
  24. 24. Intubation  Crash/emergency intubations should be avoided.  Volume protective ventilation; Lowest driving pressure and lowest PEEP as possible. Keep driving pressures < 15 cmH2O.  Moderate sedation to prevent self-extubation  Trial of inhaled Flolan (epoprostenol)  Prone positioning.
  25. 25.  There is however, no evidence to support this fear.  High flow nasal cannula is a better option for the patient and the health care system than intubation and mechanical ventilation.  CPAP/BiPAP may be used in select patients, notably those with COPD exacerbation or heart failure.
  26. 26. 14.Salvage Treatments  Plasma exchange  ECMO (extracorporeal membrane oxygenation)  High dose corticosteroids; 120mg methylprednisolone q 6-8 hourly  Siltuximab and Tocilizumab (IL-6 inhibitors) 15. Treatment of Macrophage Activation Syndrome (MAS)  A ferritin > 4400 ng/ml is considered diagnostic of MAS.
  27. 27.  “High dose corticosteroids.” Methylprednisolone 120 mg q 6-8 hourly for at least 3 days, then wean according to Ferritin, CRP, AST/ALT .  Ferritin should decrease by at least 15% before weaning corticosteroids.  Consider plasma exchange.  Anakinra (competitively inhibits IL-1 binding to the interleukin-1 type I receptor) can be considered in treatment failures.
  28. 28. 16. Monitoring  Daily: PCT (procalcitonin), CRP,(C-reactive protein ) IL-6, BNP(brain natriuretic peptide), Troponins, Ferritin, Neutrophil-Lymphocyte ratio, D-dimer and IL-6 and Ferritin track disease severity closely (although ferritin tends to lag behind CRP).  Thromboelastogram (TEG) on admission and repeated as indicated.  Patients receiving IV vitamin C.
  29. 29. 17. Post ICU management a. Enoxaparin 40-60 mg s/c daily b. Methylprednisone 40 mg day, the wean slowly c. Vitamin C 500 mg PO BID d. Melatonin 3-6 mg at night
  30. 30. Thank you

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