[IM] COVID-19 managment(JAMA)

[Category] Topic; 1. Workup; 2. Management; 3. Tip and Teaching point; 4. References;

Intro: uncertainty remains about the reasons that some patients develop respiratory failure and others have no to minimal symptoms.

Assessment: 

- CBC with differential(lymphocyte count) , CMP, PT/PTT, Troponin, BNP, D-dimer, LDH, CK, Ferritin, CRP. 

Tx. Supportive care: 

[Evaluation of severity, in ARDS = 1) bilateral radiographic opacities and 2) sufficient degree of hypoxemia (PaO2/FiO2 < 300, cf: Horowitz index = Carrico index, and P/F ratio, normal is ~ 400-500 mmHg)(=A-a gradient present? Because PaO2 should = FiO2 x 500 (e.g. 0.21 x 500 = 105 mmHg)); Mild: 200-300(mortality 27%), Moderate: 100-200(32%), severe <100 (45%); but PaCO2 is normal, and shunt is not suspected !! 

- Ventilation: lung protective, low Td Volume(4-8cc/kg predicted body weight), 

                      plateau pressure to 30 cm H2O or less

- Sedation, analgesia appropriately. NMB briefly as needed(if there is dyssynchronies)

- Avoid too much of fluids. Out of shock, then aggressive diuresis. => remove fluid strategy.

- P/F ratio(Horowitz index) <150 = Prone positioning

- considering ECMO(veno-veno), if prone position is not enough. 

- Intubation as needed(like other population without COVID-19)

- Medical treatment: 

 - If sats decline to 94% or lower/pt placed on O2, then will initiate Remdesivir and 

   dexamethasone and discuss plasma consent.  (Pt aware and agreeable that she may qualify for available treatments if develops hypoxia but otherwise supportive care and IS mgmt alone for now)

 - Evidence: remdesivir shortens the time to recovery.

                   RECOVERY trial demonstrated a survival benefit of dexamethasone treatment in 

                   patients with COVID-19 who require oxygen or mechanical ventilation. 

 

- DVT ppx with heparin sq. 

 - cf) hydroxychloroquine and lopinavir/ritonavir have proven ineffective. IL-6 blocker..

 - not requiring oxygen = dexamethasone may be harmful