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Management of Mild to Moderate COVID cases -VSGH Protocol

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COVID-Management

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Management of Mild to Moderate COVID cases -VSGH Protocol

  1. 1. Dr A P Naveen Kumar
  2. 2.  Patients need to be clinically staged which would help us in admission to an appropriate COVID 19 area and further management Proposed clinical staging system  Stage I: Asymptomatic to mild (early infection)  Stage II A: moderate (pulmonary involvement without hypoxia)  Stage II B: moderate (pulmonary involvement with hypoxia)  Stage III: severe (systemic hyperinflammation with cytokine storm) 2
  3. 3.  • ILI is defined as one with acute respiratory infection – with fever ≥ 380 C (100.40F) and – cough – with onset within last 10 days  • SARI is defined as one with acute respiratory infection – with fever ≥ 380 C (100.40F), – cough – with onset within the last 10 days and requiring hospitalization  • Respiratory failure – Represents the failure of the lung to maintain adequate gas exchange – Characterized by ABG abnormalities: PaO2< 60 mmHg with or without hypercarbia - PaCO2> 46 mmHg (with drop in pH<7.30)
  4. 4.  The median incubation period is 5.1 days (range 2–14 days)  The precise interval is uncertain.  The period of infectivity starts 2 days prior to onset of symptoms and lasts up to 8 days
  5. 5.  Trouble breathing  Persistent pain or pressure in the chest  New confusion  Inability to wake or stay awake  Bluish lips or face
  6. 6.  Adults 60 years and older  Children younger than 2 years old  Pregnant women and women up to 2 weeks after the end of pregnancy  People who live in nursing homes and other long-term care facilities
  7. 7.  COPD ,Moderate to severe Asthma  CHF ,CAD ,Cardiomyopathies  T2DM  CKD CLD  Obese and BMI > 30  Sickle cell disease  Cancer  Immunocompromised  Pregnancy  CVA
  8. 8.  A. A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), AND a history of travel to or residence in a location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset; OR  B. A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to symptom onset; OR  C. A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND requiring hospitalization) AND in the absence of an alternative diagnosis that fully explains the clinical presentation
  9. 9.  A. A suspect case for whom testing for the COVID-19 virus is inconclusive. OR  B. A suspect case for whom testing could not be performed for any reason.
  10. 10.  A person with laboratory confirmation of COVID- 19 infection, irrespective of clinical signs and symptoms
  11. 11.  As per data from Integrated Health Information Platform (IHIP)/ Integrated Disease Surveillance Programme (IDSP) portal case investigation forms for COVID 19 (n=15,366) 11-6-20  fever (27%)  cough (21%)  sore throat (10%)  breathlessness (8%)  Weakness (7%)  running nose (3%)  and others 24%.
  12. 12. Reported symptoms were as follows -USA  Fever (43.1%)  Cough (50.3%)  Shortness of breath (28.5%)  Myalgia (36.1%)  Runny nose (6.1%)  Sore throat (20%)  Headache (34.4%)  Nausea/vomiting (11.5%)  Abdominal pain (7.6%)  Diarrhea (19.3%)  Loss of smell or taste (8.3%)
  13. 13. Clinical presentation  Patients with uncomplicated upper respiratory tract infection, may have mild symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache Clinical parameters  Without evidence of breathlessness or Hypoxia (normal saturation). Remarks Managed at Covid Care Centre
  14. 14. Clinical presentation  Pneumonia with no signs of severe disease Clinical parameters  Adolescent or adult - of dyspnea and or hypoxia, fever, cough, including SpO2  <94% (range 90-94%) on room air, Respiratory Rate more or equal to 24 per minute.  Child with respiratory distress  Fast breathing (in breaths/min):  < 2 months: ≥ 60  2–11 months: ≥ 50;  1–5 years: ≥ 40 Remarks Managed in Dedicated Covid Health Centre (DCHC)
  15. 15. Clinical presentation  Severe Pneumonia Clinical parameters  Adolescent or adult: with clinical signs of Pneumonia plus one of the following; respiratory rate >30 breaths/min, severe respiratory distress, SpO2 <90% on room air.  The diagnosis is clinical; chest imaging can exclude complications Remarks Managed in Dedicated Covid Hospital
  16. 16.  Acute life-threatening organ dysfunction caused by a dys-regulated host response to suspected or proven infection.  Signs of 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
  17. 17.  Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level > 2 mmol/L
  18. 18. 18  Counsel the patients to self record their temperature, pulse and saturation twice daily.  All the patients should be advised to do 6 min walk test and record their saturation and pulse rate.  The patient should be counselled to inform immediately in case of worsening clinical status.  After completion, history, vitals to be entered in the case sheet .  Calculate BMI and note down the GRBS for diabetics at the time of admission.  Now let us discuss how to substage the patient given the clinical details.
  19. 19. a) Asymptomatic patients without comorbidities and age<60 yrs Saturations more than 95%, no fever, no tachycardia. Investigations required a) Baseline ECG (Calculate Qtc) b) Chest radiograph (Look for chest infiltrates) c) Haemogram (Look for leucopenia, lymphopenia, thrombocytopenia) d) RFT e) LFT f) RBS g) CRP h) Sr Uric acid  These patients can be advised for home quarantine if it is feasible and above reports are normal. 20
  20. 20. 21 Treatment for Stage 1a a) Tab. Vitamin C 500mg BD for period of isolation b) Tab. Zincovit B.D for period of isolation c) Vit D 60k U once weekly for 8 weeks if not taken recently
  21. 21.  This stage includes  Symptomatic / URTI without comorbidities. These include a) Fever or chills b) Cough c) Fatigue d) Muscle or body aches e) Headache f) New loss of taste or smell g) Sore throat h)Congestion or runny nose i) Nausea or Vomiting j) Diarrhoea. 22
  22. 22. 23  Investigations required for Stage 1b  Haemogram(Look for leucopenia, lymphopenia, thrombocytopenia)  RFT  LFT  RBS  CXR (Look for chest infiltrates)  ECG (Baseline Qtc)  CRP In case of persistent fever  Any other investigation deemed to be necessary like blood cultures, CUE and Urine c/s, USG Abdomen and Procalcitonin, tropical fever work up ( Dengue antigen and serology, Smear for MP, Strip for Pf)  If persistent fever spikes present beyond Day 5 , send inflammatory markers, (CRP, Ferritin, LDH, D-dimers, LDH, CT if needed)
  23. 23. 24 Treatment of Stage 1B a) Tab. Vitamin C 500mg BD continue until period of isolation. b) Tab. Zincovit BD until isolation period. c) Vit D3 60k U once weekly for 8 weeks. d) Tab. Dolo (paracetamol) 650 mg can be given upto qid dosage. Addition of antibiotics or HCQS is at the discretion of treating physician OR Doxycycline + Ivermectin 12 mgs OR Fabipiravir
  24. 24. • 1. Neutrophil lymphocyte ratio > 3.5 -- monitor CBP with differentials (consider only if leucopenia present)  2. Resting tachycardia– closely monitor Pulse, BP, Saturation  3. 6 min walk deoxygenation,--(Refer to Level 2 care) 4. Persistent fever spikes beyond day 5 and raised inflammatory markers( alert level 2 care team) 25
  25. 25.  To Oxygen ward  1. Respiratory rate > 24/min (or)  2. SpO2 < 94% on room air. (or)  3. PaO2/FiO2 level <300 (Mild ARDS)  To COVID ICU • 1. Moderate/Severe ARDS  2. Multi-organ dysfunction  3. Shock  4. Transfer from ward to ICU if needs mechanical ventilation/closer monitoring. 26
  26. 26. • Asymptomatic or Symptomatic / URTI with comorbidities a) obesity b) Age>60 years- c) DM d ) HTN/IHD e) COPD or any chronic lung disease f) CLD g) Immuno-compromised state h) CKD i) CVA j) Malignancy 27
  27. 27. 28 Investigations required for Stage 1c a) Haemogram with ESR (Look for leucopenia, lymphopenia, thrombocytopenia) b) LFT c) RFT d) RBS e) CXR (Look for chest infiltrates) f) Spo2 at rest and post 6 min walk. g) ECG (Calculate baseline Qtc) h) CRP(100mg/L) i) LDH (>245 U/L), CPK (2*ULN) j) S.ferritin (>500ug/L) k) D-Dimer, PT, aPTT, INR (D-dimer>1000ng/mL) l) S. Triglycerides m) Trop I levels (>2*ULN) n) Do procalcitonin if persistent fever spikes present along with blood cultures, Complete urine exam and urine culture and tropical fever work up)
  28. 28. 29  Treatment for Stage 1c a) Tab. HCQ 400mg stat f/by 200mg BD for 4 days or Doxycycline BID for 5 days plus Ivermectin 12 mgs for 3 days b) Tab. Vitamin C 500mg BD till the period of isolation. c) Tab. Zincovit B.D. till the period of isolation. d) Vit D 60k U once weekly for 8 weeks. e) Tab. DOLO( paracetamol) 650 mg upto QID f) Inj. Clexane 0.6 cc s/c OD (to all patients) and BD if high D-dimer or an increasing d-dimer levels (HASBLED score less than 3 for therapeutic dose) g) Consider steroids if HRCT is showing moderate involvement h) Antibiotics as per treating physician discretion
  29. 29. • Pneumonia/ Lower respiratory tract infections without hypoxia/breathlessness • Consolidation/ground glass opacities on imaging (Cxray or HRCT)  Investigations required Haemogram (Look for leucopenia, lymphopenia, thrombocytopenia) LFT RFT RBS ECG (Baseline Qtc) Chest radiograph (monitoring progression of pneumonia) CRP 30
  30. 30.  CRP (>100 mg/L)  D-dimers ,PT, aPTT, INR (D-dimer>1000ng/mL)  Trop I(>2*ULN)  LDH (245 U/L), CPK (2*ULN)  Ferritin(>500ug/L)  Procalcitonin (if suspecting infection)  Blood cultures 2 sets mandatory before starting IV antibiotics, CUE, Urine c/s  Other tropical fever ( Dengue antigen and Serology, Smear for MP, Pf strip test, )work up if necessary  Any other investigation required at the discretion of treating physician. 31
  31. 31. Treatment a) Tab. HCQ 400mg stat f/by 200mg BD for 4 days or Doxycycline BID for 5 days plus Ivermectin 12 mgs for 3 days b) Tab. Vitamin C 500mg BD till the period of isolation. c) Tab. Zincovit B.D till the period of isolation. d) Vit D 60k U once weekly for 8 weeks. e) Tab. DOLO (paracetamol) 650 mg upto QID f) Inj. Clexane 60mg s/c OD (to all patient) and BD if high D-dimer or an increasing d-dimer levels (HASBLED score<3) g) Consider steroids if HRCT is showing moderate involvement g) Antibiotics as per treating physician discretion. 32
  32. 32. • 1. Neutrophil lymphocyte ratio > 3.5,--monitor daily CBP with differentials  2. Resting tachycardia-- monitor pulse, BP, saturation. 3. 6 min walk test desaturation  4. Raised inflammatory markers 33
  33. 33. How do we recognise? Tachypnea and Hypoxia at rest  Investigations of stage 2b : Haemogram (Look for leucopenia, lymphopenia, thrombocytopenia) Repeat CBC,DC daily RFT (Repeat daily) RBS CRP LFT (Repeat daily) ECG (Baseline Qtc) Chest radiograph (monitoring for progression of pneumonia), HRCT chest ABG (Repeat daily) 34
  34. 34. Treatment of Stage 2b a) Tab. HCQ 400mg stat f/by 200mg BD for 4 days b) Tab. Vitamin C 500mg BD till the period of isolation. c) Tab. Zincovit B.D till the period of isolation d) Vit D , 60k U once weekly for 8 weeks. e) Tab. DOLO(paracetamol) 650 mg upto QID f) Inj. Clexane 60mg s/c OD and BD if high D-dimer or an increasing d- dimer levels.(HASBLED score<3) g) Antibiotics as per treating physician discretion. h) i) Inj. Methyl Prednisolone 40mg IV BD-0.5-1 mg/kg body weight for 3 to 5 days. If stable can switch to oral form Or Inj. Decadron 6- 8mg IV -0.1-0.2 mg/kg body weight 35
  35. 35. • 1. Neutrophil lymphocyte ratio > 3.5,--monitor daily CBP with (consider leucopenia) differentials  2. Resting tachycardia-- monitor pulse, BP, saturation  3. Raised inflammatory markers-  If HCQs cannot be given for any reason like prolong Qtc or G6PD deficiency, Ivermectin 12mg dose for 3 days with Doxycycline 100 mg BD for 5 days may be considered. 36
  36. 36. GENERAL GUIDELINES  Continue the same antihypertensives which the patient has been using unless there is contraindication regarding prolonged Qtc like beta blockers.  GRBS to be monitored TID (premeal) by the patients.  Continue the same medications for DM, if well controlled . If GRBS more than 200mg/dL consider use of Basal or short acting insulin as is necessary.  Carefully adjust drug doses and monitor patients in case of CKD, and CLD.  Always take speciality consultations as and when required.  Those patients who have been started on steroids, monitor GRBS TID, electrolytes every alternate day. Add folic acid 5mg and calcium 500mg BD to the treatment protocol. 37
  37. 37. Finger Pulse Oximeter for continuous monitoring of Heart rate and Oxygen saturation  • Start oxygen with Mask at saturation of 94% or lower  • HFNC to be used if there is failed oxygen therapy and Non-invasive ventilation (NIV) to be used appropriately with two limb circuit expiratory filters  • Counselling of COVID19 patients ( By Counsellor/psychologist/psychiatrist)  • Normal feeding, no dietary restrictions, good oral hydration  • Maintenance IV fluids (If indicated)  • Maintain blood glucose levels <180 mg/dl.  • If Patient is on ACE inhibitors/ARBs, should be continued  • Avoid using NSAIDs other than Paracetamol Unless Absolutely Necessary  • Avoid using Nebulized drugs to avoid aerosolization of virus. PREFER MDI with SPACER  • Antibiotic selection in case of superadded bacterial pneumonia should be according to institution antibiogram. Supportive Care
  38. 38. Dose:  Tab HCQ 400MG BD FOR 1 DAY Followed by 200MG 1-0-1 X 4 Days CONTRAINDICATION FOR HCQS  QT INTERVAL > 480ms  • Pre-existing cardiomyopathy and cardiac rhythm disorders  • History of Unexplained Syncope  • Retinopathy,  • Hypersensitivity to HCQ or 4-aminoquinoline compounds  • G6PD deficiency  • Epilepsy  • Hypokalemia (K+ < 3 Meq) Hydroxychloroquine (HCQS)
  39. 39.  Pro Coagulant factors are increased in COVID-19 infection and associated with increased risk of thrombosis  The most marked abnormality is an elevation of D-Dimer (if D-dimer is more than 1000ng/ml) but without a parallel fall in platelet or prolongation of clotting time  Dose:  Inj ENOXAPARIN 40MG S/C Once daily for mild and moderate. Twice daily in severe cases  Other options:  • Inj Fondaparinux 2.5mg OD SC  • Unfractioned Heparin 5000 Units BD SC  Contraindications:  ESRD, active bleeding, emergency surgery, platelets < 20,000/mm, BP >200/120 mmHg)
  40. 40.  may be considered in patients with moderate disease (those on oxygen) with none of the following Contraindications:  AST/ALT > 5 times Upper limit of normal (ULN)  Severe renal impairment (i.e., eGFR < 30ml/min/m2 or need for hemodialysis)  Pregnancy or lactating females  Children (< 12 years of age)  Dose: 200 mg IV on day 1 followed by 100 mg IV daily for 4 days (total 5 days)  100mgs-To be given in 100ml Normal Saline over 1-2 hours
  41. 41.  may be considered in patients with severe disease with progressively increasing oxygen requirements and in mechanically ventilated patients not improving despite use of steroids. Long term safety data in COVID 19 remains largely unknown. Special considerations before its use include:  IL-6 levels 50-100 fold higher than normal (Normal range 0 - 9.5pg/ml  Worsening trend of the inflammatory markers (Ferritin, LDH, CRP)  Deteriorating clinical condition with worsening of PaO2/Fio2 ratio (more than 25% deterioration from the immediate previous value)
  42. 42. Contraindications  PLHIV, those with active infections (systemic bacterial/fungal)  High Serum. Procalcitonin, Tuberculosis, active hepatitis, Absolute Neutrophil Count < 2000/mm3 and Platelet count < 1,00,000/mm3  hepatic and renal impairment; patients on chronic steroid therapy  Paediatric patients <18 years old; Pregnancy and, Nursing mothers  Dose: 8mg/kg (maximum 800 mg at one time) given slowly in 100 ml NS over 1 hour; dose can be repeated once after 12 to 24 hours if needed
  43. 43.  may be considered in patients with moderate disease who are not improving (oxygen requirement is progressively increasing) despite use of steroids. Special prerequisites while considering convalescent plasma include:  ABO compatibility and cross matching of the donor plasma  Neutralizing titer of donor plasma should be above the specific threshold (if the latter is  not available, plasma IgG titer (against S-protein RBD) above 1:640 should be used)  Recipient should be closely monitored for several hours post transfusion for any transfusion related adverse events  Use should be avoided in patients with IgA deficiency or immunoglobulin allergy  Dose: Dose is variable ranging from 4 to 13 ml/kg (usually 200 ml single dose given slowly over not less than 2 hours
  44. 44.  Favipiravir RTP selectively inhibits RNA polymerase  Indications: mild to moderate cases of COVID19 in adults >18yrs old  Dose: 1800mg bid followed by 800mg bid upto maximum of 14days  Contraindications: Hyperuricaemia, severe hepatic & renal impairment, Pregnant women and lactating mothers  Side Effects: increased Uric Acid levels, diarrhea, decreased neutrophil counts, increase in AST/ALT levels  Drug Interactions: metabolised partly by Aldehyde Oxidase(AO) and partly by Xanthine Oxidase(XO). Precauitons for co-administration with Pyrazinamide, Repaglinide, Theophyline, Famciclovir
  45. 45.  CT chest is not recommended routinely  If patient progressively deteriorates clinically with worsening of hypoxia , HRCT can be considered at the discretion of physician  If PTE is suspected, ECG, 2 D Echo and CT chest 50
  46. 46. •CO-RADS is a categorical assessment scheme used for reporting of chest CT patients, suspected of COVID-19. •It represents the level of suspicion for pulmonary involvemen •For example, if CO-RADS is level 5 then there is very high surety for Typical COVID-19 findings.
  47. 47. CO-RADS LEVEL OF SUSPICION FOR COVID-19 INFECTION CT Findings CO-RADS 1 No Normal or non-infections abnormalities CO-RADS 2 Low Abnormalities consistent with infections other than COVID-19 CO-RADS 3 Intermediate Equivocal findings for COVID-19 infections CO-RADS 4 High Abnormalities suspicious for COVID-19 infection CO-RADS 5 Very high Typical COVID-19 findings CO-RADS 6 PCR +
  48. 48. HRCT REPORT TEMPLATE LOW DOSE H.R.C.T. CHEST SCREENING (L.D.C.T.S.): IMPRESSION: Findings are suggestive of atypical viral pneumonia, possibility of COVID-19 infection. (CO-RADS V). CT severity score 9 / 25 (Moderate) CO-RADS 5 means there is very high suspicion of COVID 19 infection in this particular patient with typical COVID-19 infection
  49. 49. 5 % INFECTED 5-25 % INFECTED 25-50 % INFECTED 50-75 % INFECTED  75 % INFECTED : SCORE 1 : SCORE 2 : SCORE 3 : SCORE 4 : SCORE 5 Score calculation is done based on each lobe involvement. Each lobe has maximum score 5. And so 5 lobes has maximum score of 25. For example, score 5 means that lobe is > 75% involved or affected by COVID- 19.
  50. 50. SCORE CT SEVERITY < 8 MILD 9 - 15 MODERATE > 15 SEVERE
  51. 51. HRCT REPORT TEMPLATE LOW DOSE H.R.C.T. CHEST SCREENING (L.D.C.T.S.): IMPRESSION: Findings are suggestive of atypical viral pneumonia, possibility of COVID-19 infection. (CO-RADS V). CT severity score 9 / 25 (Moderate) CT SEVERITY SCORE 9 OUT OF 25 means lungs are moderately infected with COVID-19 in this particular patient. CT Severity %Invol ve ment Sco re Right upper lobe 5 to 25% 2 Rt middle lobe 5% 1 Right lower lobe 25% 2 Left upper lobe 5 to 25% 2 Left lower lobe 5 to 25% 2 Total 9 /25
  52. 52.  57
  53. 53. THANK YOU

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