05/10/2020
*Some practical points in COVID management:*👇
*Fabiflu:* not found useful. (Seen many patients who deteriorated on Fabiflu as compared to Ivermectin and Doxy combination).
*Ivermectin* better than Fabiflu. Many trials also came in favour of Ivermectin.
*Remedesivir* works better in first 10 days..Can be considered in mild cases also where fever persists beyond 4-5 days. CT score more than 8. Can use in CT score less than 8 with dense consolidation (rather than GGO), high fever without raised CRP especially in elderly and with co-morbidities even with normal CT too.
*Steroids should be strictly avoided* in
1. Asymptomatic
2. Mild symptoms less than 7 days
3. CT score less than 8 with disease duration less than 5 to 7 days
4. Viremia phase (high fever with normal CRP and CT)
*Steroids should be used in all moderate and severe cases* i.e. all patients with SPO2 less than 94 irrespective of day of onset of symptoms. All these patients should receive 80 to 120 mg MP/day.
*Most important lab investigation for COVID is CRP* (from reliable lab). CRP should be guide for steroid dose. High CRP....Use higher dose of steroid. ( Remember CRP is some cases can be because of bacterial infection, UTI, line sepsis etc. In such cases, don't escalate steroids. Taper steroids and cover with appropriate antibiotic. Use Procal, WBC, cultures as a guide.
*IL 6 results are very unreliable* due to following reasons
1. Lab method are not standardized. Same sample can give different readings in different labs.
2. Collected blood sample transport delays, temperature exposure alters IL 6 values.
Many stable patients can erroneously have IL 6 values in hundreds or thousands too.
*Clinicoradiologic and CRP (from reliable lab) should be the main criteria to use steroids.*
Almost all patients with CRP above 100 should be considered in cytokine storm and higher doses of steroids should be considered. In such cases daily CRP monitoring should be done.
Other markers such as ferritin, LDH etc are not so specific... Ferritin seem to rise with delay (CRP rises earlier than Ferritin). Repeating CRP is more useful than ferritin or LDH.
*D Dimer also important marker for treatment decision after CRP* and Procal. All hospitalised patients should receive LMWH 40 mg daily. If above 500 then consider 60 OD to 60 BD. If above 1000, then 60 BD. Look for creatinine, platelets,INR etc and dose adjustment in LMWH. Patients on 60 BD, daily Hb, Malena etc should be observed.
*Does the patient gives clue before going into cytokine storm?*
Yes. We can predict. If patient in second week having SOB (even with previous normal CT), rising CRP above 50, CT worsening etc. points towards impending cytokine storm. Daily CRP monitoring and steroids dose adjustment is crucial here. Selected patients improved with pulsed steroid i.e.500 mg of MP once daily for 3 days etc.
(👆All above views from personal experience, may vary from guidelines.
: Dr Chandrakant Tarke) (Pulmonologist)
