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![Tocilizumab
tocilizumab for select patients on low-flow oxygen if they are
clinically progressing toward high-flow oxygen despite initiation
of dexamethasone and have significantly elevated inflammatory
markers (eg, C-reactive protein [CRP] level ≥75 mg/L).](https://image.slidesharecdn.com/covid-19managementupdate-210411120302/75/Covid-19-management-update-Sohag-Heart-Center-Experience-68-2048.jpg)
Uploaded byEmad Qasem
Covid 19 management update - Sohag Heart Center Experience
This document provides guidance on the management of COVID-19 patients based on the experience of Sohag Heart Center in Egypt. It discusses evaluation, general management, specific therapies, and care of critically ill and non-hospitalized patients. For non-hospitalized patients, it recommends symptomatic treatment and hospitalization for those at higher risk. For hospitalized patients, it suggests supportive care including oxygen supplementation, anticoagulation for prevention of thromboembolism, and judicious use of antibiotics. It recommends against medications like hydroxychloroquine, ivermectin, and favipiravir outside of clinical trials due to lack of proven benefit. For critically ill patients, it supports treatments like dexamethasone,
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Covid 19 management update - Sohag Heart Center Experience
- 1. COVID-19 MANAGEMENT UPDATE Sohag HeartCenter Experience Emad M. Qasem Cardiology Department, Sohag Heart Center Associate Alumni, CSRT, Harvard Medical School
- 2.
- 3. ILOS: Management of hospitalizedadults • Evaluation • General management • COVID-Specific therapy • Management of Hypoxemia and ARDS • Special considerations • Patient discharge
- 4.
- 5. BEFORE WE GO… What about Non-hospitalized patients?
- 6. Non-hospitalized patient • Mildcase • Symptomatic. • No signs of pneumonia • No leucopenia or lymphopenia
- 7. How to treatNon-hospitalized patient • Assess the risk. • Symptomatic (> 3 symptoms) risky patients should be hospitalized Risk score ≥ 65 y Age Clinical Data Uncontrolled comorbidities (DM, HTN) ≥ 40 BMI Pregnancy Active malignant condition / Chemotherapy Immunosuppresive medications ≥ 110 b/m HR Examination findings ≥ 25 c/m RR ≤ 92 % Saturation > 3.1 Neutr/lymph ratio Lab results
- 8.
- 9. Chloroquine and Hydroxychloroquine… •We suggest NOT using hydroxychloroquine or chloroquine given the lack of clear benefit and potential for toxicity. • Several large randomized trials failed to identify a mortality or other clinical benefit for hospitalized patients with COVID-19.
- 10.
- 11. Ivermectin in guidelines… Noteven a word !
- 12. Ivermectin… proposed asa potential therapy based on in vitro activity. but the drug levels used in vitro far exceed those achieved in vivo with safe drug doses. receipt of ivermectin was associated with a lower mortality rate; however, patients who received ivermectin were also more likely to receive corticosteroids (Potential confounders!) we do not use ivermectin outside of clinical trials.
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- 14.
- 15.
- 16. Ivermectin investment ?… 8 ongoing clinical trials on ivermectin in EGYPT alone Out of total 29 studies worldwide !!
- 17. Favipiravir… Used totreat influenza virus. early trials suggested some benefit. immunomodulatory agents were administered in these studies. the results are not accurate due to potential confounders.
- 18. Anti-thrombotic therapy… • Patientswho are receiving anticoagulant or antiplatelet therapies for underlying conditions should continue these medications if they receive a diagnosis of COVID-19 (AIII). • For non-hospitalized patients with COVID-19, anticoagulants and antiplatelet therapy should not be initiated for the prevention of venous thromboembolism (VTE) or arterial thrombosis (AIII). • In non-hospitalized patients with COVID-19, markers of coagulopathy, such as D-dimer level, prothrombin time, fibrinogen level, and platelet count, should not routinely be obtained (AIII)
- 19.
- 20. Take Home messages… •Don’t use antiplatelets. • Routine use of anticoagulation is NOT indicated. • Routine use of antibiotics is NOT indicated. • Ivermectin NOT to be used outside clinical trials. • Hydroxychloroquine, Chloroquine, Ivermectin and Favipiravir showed no benefit for patients up till now.
- 21.
- 22. Classify Patient Severity Criticallyill Severe case Moderate case ICU Intermediate care Ward Admit to More than 50% involvement Progressive lesion within 24/48 hours More than 50% involvement Progressive lesion within 24/48 hours Pneumonia CT findings Leucopenia & lymphopenia Leucopenia & lymphopenia Leucopenia & lymphopenia LAB RR > 30 SaO2 < 92% on oxygen PaO2/FiO2 < 200 RR > 30 SaO2 < 92% Room air PaO2/FiO2 < 300 Respiratory indices
- 23. EVALUATION features associatedwith severe illness Elevations in: D-dimer >1000 ng/mL (normal range: <500 ng/mL) CRP >100 mg/L (normal range: <8.0 mg/L) LDH >245 units/L (normal range: 110 to 210 units/L) Troponin >2× the upper limit of normal Ferritin >500 mcg/L (normal range: females 10 to 200 mcg/L; males 30 to 300 mcg/L) CPK >2× the upper limit of normal (normal range: 40 to 150 units/L) Decrease in: Absolute lymphocyte count <800/microL (normal range for age ≤21 years: 1800 to 7700/microL)
- 24. NOTES laboratory featuresare associated with severe disease but they have no prognostic value.
- 25.
- 26. DAILY LAB * •Complete blood count (CBC), focus on the total lymphocyte count. • Complete metabolic panel • Creatine kinase (CK) • C-reactive protein (CRP)
- 27. EVERY OTHER DAYLAB • Prothrombin time (PT)/partial thromboplastin time (PTT)/ INR. • D-dimer.
- 28. Baseline and repeatif abnormal • Lactate dehydrogenase, repeated daily if elevated • Troponin, repeated every two to three days if elevated. • Electrocardiogram (ECG), with at least one repeat test after starting any QTc-prolonging agent.
- 29. Other LAB: • hepatitisB virus, hepatitis C virus, and HIV antigen/antibody testing (could affect interpretation of transaminase elevations and exacerbate hepatotoxicity of certain therapies).
- 30.
- 31. Echocardiography • not routinely,only in the following cases: • increasing troponin levels with hemodynamic compromise. • other cardiovascular findings suggestive of cardiomyopathy.
- 32.
- 33. Repeating imaging • aportable chest radiograph is sufficient to exclude complications ex, Pneumothorax. • reserve chest CT for circumstances that might change clinical management.
- 34. GENERAL MANAGEMENT OF SEVERELYILL COVID-19 PATIENTS
- 35. 1. Antibiotic therapy 2.Treatment for Influenza virus. 3. Prevention of Thromboembolism (Anti-coagulation). 4. Use of NSAIDs. 5. Nebulizers. 6. Specific therapy; ACE inhibitors, Statins, Aspirin and immuno-modulators.
- 36. Antibiotic and antiviraltherapy…
- 37. Empirical treatment • empirictreatment for community-acquired pneumonia (CAP) is reasonable when the diagnosis is uncertain. Especially if new fever after resolving with new consolidation on chest imaging. • empiric therapy for influenza for patients hospitalized with suspected or documented COVID-19 in locations where influenza virus is circulating.
- 38. Empirical Antibiotics forCAP CAP— NOT in the ICU Empiric therapy No co-morbidity: Atypicals—M. pneumoniae,, S. pneumo, viral Co-morbidity: S. pneumo, anaerobes, coliforms, H. influenzae,M. catarrhalis, Ceftriaxone 1 gm IV q24h + azithro 500 mg IV q24h CAP, hospitalized—IN ICU Empiric therapy S. pneumoniae, H. influenazae, Moraxella sp., Legionella sp. Rarely S. aureus. Levofloxacin. If G-ve Bacilli is suspected and/or life threatening infection: Anti-pseudomonal beta-lactam (4th generation cephalos, piperacillin/tazobactam, imipenem, meropenem + (respiratory FQ Or aminoglycoside). Add azithro if no FQ
- 39. Influenza Anti-viral therapy •Recommended for risky patients (old age > 65 years with multiple comorbidities or BMI > 40). • treatment of patients with severe influenza, oseltamivir is the preferred agent; peramivir may be used for patients who cannot tolerate oral therapy. • Dose of 75 mg orally twice daily for 5 days duration.
- 40.
- 41. Venous Thromboembolism Moderate andsevere cases
- 42. Venous Thromboembolism • pharmacologicprophylaxis for all hospitalized patients. • do not make changes to anticoagulation based on isolated changes in laboratory values such as D-dimer. • severe COVID-19 by itself is NOT an indication for therapeutic- dose anticoagulation.
- 43. Anti-thrombotic therapy… Hospitalizednon-pregnant adults with COVID-19 should receive prophylactic dose anticoagulation (AIII). patients with COVID-19 who experience an incident VTE event or highly suspected, should receive therapeutic doses anticoagulant (AIII). Hospitalized patients with COVID-19 should not routinely be discharged from the hospital while on VTE prophylaxis (AIII).
- 44. Full dose anticoagulation… •Full-dose anticoagulation in the following conditions: 1. documented VTE or suspected VTE in which standard confirmatory testing is not available. 2. Sudden deterioration in respiratory status in an intubated patient. 3. Physical findings consistent with thrombosis (ex, superficial thrombophlebitis ) 4. Clotting of intravascular access devices (arterial lines, CVC) despite prophylactic-intensity anticoagulation. 5. clotting in extracorporeal circuits (eg, ECMO).
- 45. Anticoagulation Use ofunfractionated heparin is not preferred, reported cases of heparin resistance. Prophylactic dosing: Fondaparinux (Arixtra) Enoxaparin (Clexane) Unfractionated heparin (UFH) 2.5 mg by SC every 24h. • 40 mg by SC every 24h • weight > 120 kg: enoxaparin 40 mg by SC every 12h 5000 units by SC every 8 or 12h. weight > 120 kg: 7500 units q12h or 5000 units every 8h
- 46.
- 47. ThrombolyticTherapy (rTPA) Indicated in: 1. Limb-threatening DVT 2. Massive PE 3. Acute stroke 4. Acute myocardial infarction
- 48. Could tPA beused for other indications?
- 49. Could tPA beused for other indications?
- 50.
- 51. NSAID minimal dataavailable. if NSAIDs are needed, we use the lowest effective dose.
- 52. nebulized medications avoidthe risk of aerosolization. Take appropriate infection control precautions if used.
- 53. ACE inhibitors/ARBs continuetreatment with these agents if there is no other reason for discontinuation (ex, AKI).
- 54. Statins and aspirin continue statins in hospitalized patients but make sure to check for transaminases level. continue aspirin unless there are concerns about bleeding risk.
- 55.
- 56.
- 57. MOHP • Moderate casesSevere cases Critically ill
- 58. For How long? daily for 10 days or until discharge whichever is shorter. Watch for adverse events !
- 59. Other considerations dexamethasone(or other glucocorticoids) not be used for either prevention or treatment of mild to moderate COVID-19 (patients not on oxygen). Monitor for the risk of hyperglycemia and an increased risk of infections (including bacterial and fungal infections)
- 60.
- 61. MOHP • Moderate casesSevere cases Critically ill
- 62. Remdesivir approved bythe Food and Drug Administration (FDA) For Hospitalized Adult and Pediatric Patients (Aged ≥12 Years and Weighing ≥40 kg). The safety and efficacy of combination therapy of remdesivir with corticosteroids have not been rigorously studied in clinical trials. suggest it reduces time to recovery, which we regard as a clinical benefit.
- 63. Remdesivir prioritize remdesivirfor those requiring low-flow supplemental oxygen, may reduce mortality. WHO suggest not using it in hospitalized patients because there is no clear evidence that it improves patient-important outcomes for hospitalized patients (eg, mortality, need for mechanical ventilation)
- 64. Remdesivir dosing… adult dose: 200 mg intravenously on day 1. followed by 100 mg daily for 5 days total. extension to 10 days if there is no clinical improvement and in patients on mechanical ventilation or ECMO. Side effects including nausea, vomiting, transaminase elevations, anemia, acute kidney injury, fever and hyperglycemia were reported.
- 65.
- 66.
- 67. Tocilizumab tocilizumab (8mg/kg as a single dose) for patients requiring high- flow oxygen or more intensive respiratory support within 24 to 48 hours of admission to ICU. Only to patients who are also taking dexamethasone (or another glucocorticoid) and generally limit it to a single dose. Check CBC and Liver function test before starting medication.
- 68. Tocilizumab tocilizumab forselect patients on low-flow oxygen if they are clinically progressing toward high-flow oxygen despite initiation of dexamethasone and have significantly elevated inflammatory markers (eg, C-reactive protein [CRP] level ≥75 mg/L).
- 69. Tocilizumab Contraindications… hypersensitivityto tocilizumab. uncontrolled serious infections. absolute neutrophil count (ANC) <500 cells/microL. platelet counts <50K. alanine aminotransferase (ALT) >5 times the upper limit. elevated risk for gastrointestinal perforation.
- 70.
- 71. Convalescent plasma… theavailable evidence does not support a clear role for convalescent plasma in patients with severe disease.
- 72.
- 73. lopinavir/ritonavir… Treatment GuidelinesPanel (the Panel) recommends against the use of lopinavir/ritonavir and other HIV protease inhibitors for the treatment of COVID-19 in hospitalized patients (AI). The Panel recommends against the use of lopinavir/ritonavir and other HIV protease inhibitors for the treatment of COVID-19 in non-hospitalized patients (AIII).
- 74.
- 75. Oxygen targets… titrateoxygen to a target SpO2 of ≥94 % during initial resuscitation ≥90 % for maintenance oxygenation.
- 76. Prone ventilation… asmuch time as is feasible and safe in the prone position. while receiving oxygen or noninvasive modalities; HFNC or noninvasive ventilation (NIV).
- 77. Next Step… NIVor Intubation noninvasive modalities may be used rather than proceeding directly to intubation. HFNC and NIV are considered aerosol generating procedures. Better to use NIV mask with a good seal and not have an anti- asphyxiation valve or port. Don’t delay the decision of intubation if needed.
- 78. Intubation have a lowthreshold to intubate patients with the following: Rapid progression over hours. Lack of improvement on >50 L/minute of high flow oxygen and a fraction of inspired oxygen (FiO2) >0.6. Evolving hypercapnia, increasing work of breathing, increasing tidal volume, worsening mental status. Hemodynamic instability or multiorgan failure
- 79.
- 80. Anticoagulation Patients with documentedVTE: • a minimum of three months of anticoagulation. Patients without documented VTE: • May need extended thromboprophylaxis but do not use routine post-discharge thromboprophylaxis. • patients with major prothrombotic risk factors such as a history of VTE or recent major surgery or trauma, and low bleeding risk may be considered for thromboprophylaxis
- 81. Why not touse routineThromboprophylaxis? The risk of post-discharge VTE appears to be similar to that of individuals hospitalized for acute medical illnesses other than COVID-19.
- 82. Anticoagulation What to use? •rivaroxaban 10 mg daily for 31 to 39 days .
- 83. Anticoagulation for non-hospitalizedpatients Only in those with other thrombotic risk factors such as prior VTE or recent surgery, trauma, or immobilization.