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Latest regarding Covid Management

Posted By: PANKAJ N CHOUDHARY

: Aug-27-2020

Once covid is diagnosed get a baseline CBC, LFT, KFT, CRP, d- Dimer, IL6 (if indicated), LDH, Ferritin, Trop T, ECG, baseline CXR ,CT chest (if indicated)
 
Ask for replication score(CT values) in Covid RT PCR test. It indicates how infective you are for other people. Any score above 25 is generally non infectious especially if you crossed 10 days &
asymptomatic for 3 consecutive days.
 
Viral replication generally stops by 9th day which means if you want any benefit of anti viral it should be given within 9 days.
 
RT PCR may be negative in 20 to 30% cases of nfection. So dont forget to rely on clinical, biochemical & and radiological guidance to diagnose a case. Sensitivity of Covid rapid antigen is around 50 to 60% but specificity is close to 100%. So in symptomatic patients if antigen is positive then there is no need to do RT-PCR.
 
The host inflammatory response to Covid disease is that which causes damage not the virus that is termed as Cytokine storm syndrome where there is hyper stimulation of patient's own
immune system that causes muscle organ dysfunctions.
 
CRP and LDH are the first to raise even before CT changes.Clinically dangerous symptoms are fever, myalgia and exhaustion which indicate high inflammation in the body. Steroids and anti coagulants are the corner stone of the treatment. At present steroids are recommended for people who become hypoxic. Start early steroid irrespective of hypoxia especially if CRP and other inflammatory markers are elevated.
 
Oral prednisolone 20mg or Tab Dexa 4mg /day for 5 to 7 days would help if there are mild symptoms.Steroids also prevent long term lung fibrosis.
Regarding anti coagulation Inj Clexane 1 mg/kg s/c od if d Dimer is normal and 1mg/kg s/c bd if d- Dimer is elevated. Better to start early if CT changes are seen, as the changes in CT are
actually secondary to microvascular thrombi. 
After 7 days, you can switch to oral anticoagulants/NOACS to be continued for 4- 6 weeks in appropriate patients.
Early steroids and anticoagulant will prevent longterm complications.
Inj methylprednisolone 0.5 to 1 mg/kg IV or Inj Dexa 6 mg IV are the preferred choices.Steroids may be needed for 2 to 3 weeks if hypoxia is present..Even if sugars are normal in first week
keep monitoring blood sugars regularly as long as patients are on steroids.
Regarding antivirals oral Favipiravir is indicated in mild to moderate cases & inj Remdesivir in moderate to severe patients.
HCQS is not recommended for treatment now.
Convalescent Plasma Therapy have also shown good results when given early in the course disease or during viremia phase.
It is mandatory to monitor CRP, d- Dimer every alternate day till patient is in hospital. IL6 on day 5 and day 8.
Any raise in IL6 is a marker for an impending cytokine storm and inj Tocilizumab should be considered.
 
Keep monitoring procalcitonin for secondary infection as the risk of infection is present up to two weeks.Secondoty fungal infections are very common especially in diabetic patients.
Once Tocilizimab is given patient usually don't manifest fever or raised counts as marker of infection.
Keep a low threshold for antibiotics if patient has received Tocilizimab.
Most critical period is 8 to 12 days of first symptom.But if treatment is started early as mentioned above it is very unlikely patient will land up in complications.Body will automatically
clear the virus after that.Prone position for most of the time day will make a big difference if patient is hypoxic.
CXR every 3 days is sufficient to monitor progress. Repeat CT Chest generally not indicated.Remember radiological changes may take weeks or months to clear. Don't get
panicked.
Improvement in oxygen levels is the marker for clinical improvement.
No need to monitor anything else once oxygen starts improving.
10 to 15% dont develop antibodies post covid or develop some T cell immunity or dominant IgA antibody response in respiratory mucosa and not systemic IgG response.
So post covid immunity is not guaranteed in patients who have recovered from the illness.
So people are required to follow some safety protocols even though they have recovered from Covid 19.
 
Dr Pankaj Nand Choudhry
Senior Consultant
Max Vaishali
President
IMA West Ghaziabad