CME INDIA Presentation by Dr Rajeev Jayadevan, Dr Sunny P. Orathel, Dr TV Ravi, Dr Atul Joseph Manuel, Dr Anitha Thilakan, Dr Suresh G Nair, Dr Sophia Philip, Dr Rajesh V, Dr Abraham Ittyachan, Dr Renoy Henry, Dr Paramez Ayyappath, Dr Ajith Venugopalan, Dr Junaid Rahman, Dr Deepa KA, Dr Mathews Numpelil, Dr M Narayanan, Dr Anwar Hazzein K, Dr Rajalakshmi, Dr Sreevalsan TV, Dr Sheetal Binu, Dr Zubin Paul Jacob, Dr Jithin Jose, Dr Sivaprasad PS, Dr Sunitha Daniel and numerous others who contributed to this document.
PDF link at the end of the article.
(Cochin IMA/KGMOA/API Consensus on COVID-19 Management 1.0, Dated 29th May, 2021)
25 Practical Tips
1. COVID-19 is a biphasic illness. In the first phase, also called viremic phase, virus enters our cells and multiplies. This phase typically lasts for 5-10 days, often with symptoms. Beyond day 10, ‘live’ virus is almost never found in the body in mild to moderate cases.
The second phase occurs only in the 15-20% who develop moderate to severe disease (typically after the first 5-10 days). The second phase is due to dysregulated and excessive immune response.
The maximum viral load and shedding occur around the first day of symptoms – after an incubation period of ~5 days. Since shedding starts before onset of symptoms, it spreads to other people before we can isolate the infected person.
2. Importance of documenting “Day One” of symptoms: The first symptom is sometimes not remembered by patients; a detailed history will help elicit this. Getting this date correct is important in determining the course and treatment.
For instance, if day 1 is not accurately diagnosed, a patient may seem to deteriorate on day 3 of illness while it might actually be day 8 – simply because the patient did not remember the initial symptoms that occurred 8 days ago. This can lead to confusion while planning management.
3. Steroid use: During the early viraemic phase of illness (~first 7 days) it is important to avoid steroid use because this may cause worse outcomes.
The dose should not exceed therapeutic range. Dexamethasone is started at 6 mg per day if, and when early signs of pulmonary inflammation appear, typically past day 7 of onset of symptoms. Decrease in oxygen saturation and symptoms of shortness of breath are the features of this inflammation.
Equivalent doses are Dexamethasone 6 mg = Methylprednisolone 32 mg = Prednisolone 40 mg = Hydrocortisone 160 mg.
4. Steroids should never be used prophylactically in someone with mild symptoms with an intent to “prevent progression to severe disease”. 80% of people with mild disease recover on their own; the virus leaves their body in about 7-10 days since onset of symptoms.
Pulmonary disease is not from the direct action of the virus, but from an abnormal immune response by the body, and steroids are helpful only in this subgroup of patients.
Sugars must be closely monitored in patients who are on steroids. A few patients could already be diabetics without their knowledge, because they had not been diagnosed yet.
5. Antibiotics are not routinely needed in viral illnesses such as COVID-19. Unless there is a clinical suspicion or evidence of bacterial infection, they should not be used. The initiation of steroids is not an indication to start antibiotics.
Antibiotics may destroy normal flora which are important for mucosal immunity in the respiratory tract and gut. Unwarranted use can promote widespread antibiotic resistance, as well as super-infections from multidrug resistant bacteria as well as fungi.
6. Antibiotic stewardship needs to be emphasised in all clinical settings, discouraging all unwarranted use of antibiotics. Hospital infection control committees can help regulate this, along with prevention of nosocomial infections.
Identifying coinfections (nosocomial) early will reduce mortality among the critically ill. Sending cultures proactively will help identify and treat these. Click here for ICMR study link on nosocomial infections.
7. Use of pulse oximeter at home: Good quality equipment is required to avoid wrong readings. Unless a pulse waveform is observed, the reading will not be valid. The pulse oximeter only detects the % oxygen saturation of haemoglobin, as an indirect surrogate of PaO2 or arterial oxygen concentration.
A saturation drop from 95% to 90% means that PaO2 decreases from 80 to 60 mm
Hg. When saturation drops further to 85%, it means PaO2 is quite low at 50 mm Hg (see pic).
The oxygen-haemoglobin dissociation curve is not linear. Unfortunately, the ability of a pulse oximeter to detect a drop (change) in PaO2 is the lowest at the flat top end of the curve, that is 90-100% (see yellow highlighted section). This means that for a relatively small drop in saturation (y-axis), a large drop in PaO2 (x-axis) can occur.
The curve turns steep after it dips below 90% saturation. As a result, small reductions in PaO2 are accompanied by relatively large drops in saturation in this part of the curve. As PaO2 continues to drop, oxygen delivery to tissues is further decreased.
8. Patients undergoing treatment at home must be given clear guidelines to seek medical attention if their symptoms persist past ~five days. There have been instances of individuals quickly deteriorating because of a delay in visiting the hospital.
9. How to detect worsening at home: Reappearance of fever and systemic symptoms after one week, increase in shortness of breath, excessive tiredness, inability to do daily activities or eat could be warning signs of severe disease. These symptoms could point to those who may progress to severe disease.
10. Breath count: Asking patients to take a deep breath and then count 1,2,3 (native language) rapidly till maximum may help detect those who have low oxygen levels.
With some individual variation, if the patient can count for at least 8 seconds, it roughly correlates with a saturation of 95%.
This method might be helpful where home pulse oximetry is not available. Also, called Roth score, this is not an accurate test by itself, and has even been disputed as a screening tool. Worsening of individual symptoms is a better indicator.
11. Steam inhalation has no role in COVID-19 – apart from mild symptomatic relief in those with cough, when done correctly. However, unlike medications such as paracetamol that come in prescribed doses, steam does not have a fixed dose. It is used differently by different people, often without any medical supervision. It is therefore easy to do it excessively at home, particularly after reading misleading WhatsApp claims that prolonged and frequent steaming can ‘kill the virus’.
Due to latent heat of vaporisation, steam burns are more severe than boiling water, this is a known fact in physics. Therefore, patients must be discouraged from excessive steam inhalation, which can potentially damage their mucosal lining and cause secondary infections. Dead tissue – whether from burns or from trauma – is a well-known factor contributing to mucormycosis .
12. Tocilizumab, an IL-6 inhibitor – has a narrow spectrum of action, which means that this agent will only help patients that fit certain criteria. If such agents are used in patients that do not fit there criteria, adverse outcomes could occur. Use of such agents is best left to the discretion of an expert committee at the hospital.
13. Remdesivir does not improve survival in patients, and is not recommended by WHO. Its use must be restricted to those patients who fit criteria specified in treatment guidelines. The reason it does not prolong survival is because the pulmonary complications of COVID-19 are immune-mediated – and not directly the result of virus infection of the lung.
14. CRP: Among all inflammatory markers and also considering costs, C-reactive protein is more suitable for monitoring of inpatients with COVID-19 in India.
15. Pregnancy is an important comorbidity in the Indian context. Pregnant women will benefit from COVID vaccination by reducing their chance of falling seriously ill or dying. FOGSI has supported this.
16. “Not being vaccinated” is a ‘comorbidity’. The current clinical profile of patients COVID-19 show a clear demarcation between those who been previously vaccinated and those have not been vaccinated. Those without vaccination are observed to have more severe disease. Therefore, unvaccinated status may be added as a co-morbidity, which will help guide treatment decisions.
17. There is limited evidence for the use of anti-fibrotic agents & inhaled steroids.
18. Quality of test kits is a concern as some patients have tested negative even while they were actively having COVID-19 symptoms.
19. Therefore, if someone has high pre-test probability of COVID-19 and the test is negative, they should still be treated as COVID-19, and advised to visit the hospital or clinic if they worsen while at home.
This mainly applies to family members of COVID-19 patients who might otherwise feel falsely reassured from a negative COVID test.
20. TPR (Total Positivity Rate) in a region may be falsely low because there are several instances where family members with high likelihood of COVID-19 are refusing or not showing up for testing. Their numbers will be missing in the official statistics.
21. Quality of N95 masks must never be compromised.
22. Pulmonary rehabilitation has an enormous role. The fallout of the pandemic warrants specialised pulmonary rehabilitation, requiring physiotherapists as well as respiratory therapists. This will help a large cohort of patients who survive severe COVID-19 in the future. Many of these patients will require several weeks of active treatment, and this could potentially block hospital beds otherwise. Step-down therapy is an important aspect of ensuring continued ICU bed availability.
23. The number of “Post-COVID” patients will increase in the next few months. These patients must be accommodated in all medical clinics, not just in specialised ‘post-COVID clinics’.
24. Palliative care concepts must be actively discussed in the management of those who are severely ill, with special attention to reduce suffering, and also to reduce work of breathing.
25. Viruses can mutate only if they can multiply. If we can prevent spread of virus by non-pharmaceutical interventions such as masking & social distancing, and pharmaceutical interventions such as vaccination, we can reduce the chance of more mutants arriving in the future.
Note: These tips are based on the collective experience of several doctors, compiled to be shared with other doctors. COVID-19 is an evolving topic. As evidence accumulates, guidelines will continue to change.
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