1. COVID-19 is REAL. But many of them are asymptomatic, i.e. very low exposure and no disease at all.
2. COVID-19 has no cure as of now. But the scientists are working on it.
3. COVID-19 diseases can be classified as asymptomatic, mild, moderate and severe diseases. The severe COVID-19 disease is dangerous and life threatening in most of the patients.
I have got C19 in November '20, and the smell went off just like switching off the light. On Day 5 from the onset of fever, smell was gone, and restored nearly after 10-11 days partially. I am still not sure my smell got completely recovered.
The point is if your smell is gone, it is most probably mild to moderate COVID.
4. Oxygen is the main stay of treatment. You can call it standard care therapy. Ventilators can't save most of the patients, but high flow nasal oxygen @ upto 60L/min is better in my experience.
I came to know about HFNO/HFNC back in 2018 but never used it until COVID began.
In my personal opinion, there are two entities work here -
A. severe hypoxia + hypoxic respiratory failure - presented as very low pO2 (<45), patients are in severe breathlessness. They need ventilatory support, preferably NIV. HFNC is not much useful.
B. hypoxia - Many patients presenting hypoxia in moderate range (45-65), SpO2 ranging from 80-94 without any symptoms (happy hypoxia). For these patients early detection is needed as due to 'happy hypoxia' these patients often present as almost asymptomatic and NRBM works pretty good (with antiviral Remdesivir). If NRBM fails to keep sPO2 > 94 %, use HFNC. Even if P/F ration (say for eg PO2 64 with FiO2 1.00 in HFNC - don't put these patients on IMV though P/F ratio is 64%.
Proning needs more manpower in intubated/ventilated patients - that means more chance of viral transmission among health care providers. Awake proning is good, as patients can do it by themselves, but in severe dyspnea they are not doing it frequently. Also proning in patients on HFNC does not reduce the risk of intubation.
When these severely dyspnic, abnormal GCS patients are put on mechanical ventilation - there are few strategies to be followed as these patients show ARDS on CXR - B/L patchy opacities. HRCT is better tool - ARDS along with GGO can be seen.
AC-VC mode - keep the patient sedated and paralysed by the use of paralytic agents like Atracurium/Rocurionium. As these patients have high RR and high flow demand, high flow must be set along with lung protective ventilation strategy - including low tidal volume and high PEEP for better alveoli recruitment.
In a retrospective pilot study, it has been seen that if SpO2 is not improving after intubation and initiation of mechanical ventilation - it predicts mortality.
5. Remdesivir may or may not work as an perfect antiviral in COVID-19 pneumonia. It is costly (cheapest brand costs Rs 2800 per 100mg vial in India), so don't use it randomly. But as we started using it in COVID-19 patients we have found that Remdesivir can do wonders if it is given in the viral replication phase (D2 to D8), the SpO2 improves dramatically, and requirement of oxygen support is reduced and if ground glassing is there - it gets cleared.
5A. Favipiravir - I have not used it in ICU, but advised in selected outdoor patients. So far no bad reports, and none of them progressed into severe disease. They got home based care and got recovered in time.
6. Tocilizumab, the monoclonal antibody to stop/prevent Cytokine Storm Syndrome comes with many adverse effects, and if the patient is already in ICU, on ventilatory support, Toci can put the patient at risk of developing secondary bacterial or fungal sepsis, which is absolutely life threatening. Toci should be used with caution. We have used Tocilizumab in few patients - result is 50/50 - some recovered, some died.
7. Major risk factors contributing to mortality rate, are age (at 60+ a patient is at very high risk) and co-morbidities which keep immunity down, like chronic kidney disease, chronic liver disease, uncontrolled diabetes etc.
8. I have no experience in ECMO or extracorporeal life support (ECLS) but it might help in severe disease, as it gives lungs time to recover. Frankly speaking in India ECMO is almost non existent in government setups, and in private/corporate set ups ECMO costs a bomb!
9. Lungs are most affected organ, and we already heard of lung transplant in some COVID-19 patients. Post COVID lung fibrosis is real. Lung capacity will go down, and you may not play or run as fast as before. The anti fibrotic drugs like Nintedanib & Pirfenidone used in idiopathic lung fibrosis, may be used.
10. I am adding this last point - IV fluids in COVID ARDS. Though judicious fluid strategies are said to be followed in ARDS, COVID means care givers are inside PPE and sometimes it is not possible for best care - i.e. IVC guided fluid strategy, close monitoring of vitals - like sudden drop in BP and urine output etc. And I always prefer oral fluid intake - which can be guaranteed in many centers. You calculate these factors before writing down 'total intake 1.8L - 2L per day', so being flexible may not harm a lot.
10A. Vasopressors are seldom used in COVID-19 pts, even if they are very critical and on mechanical ventilation. That means hypotension is not a regular thing with COVID-19. A 2021 journal trial also supports this fact.
11. Long COVID - which has been named as PASC (Post Acute Sequelae of COVID-19), by Anthony Fauci is also real among the patients and the affected health care workers. It is being said that PASC is seen alteast 10% of the COVID 19 patients and may be seen in moderate diseases also. Clinical symptoms like fatigue, gastrointestinal problems, mental health issues, sleep difficulties, impaired lung capacity (due to extensive fibrosis), altered/impaired smell, hearing issues, neurological issues (COVID brain fog, Read more at COVID-19 Neuro Data Bank - Biobank )- are associated in PASC after recovering from COVID-19.
No comments:
Post a Comment