Pakistani doctor provides guidelines for clinical management of COVID-19

Leading Pakistani doctor provides with guidelines to clinically manage the novel virus across Pakistan, confirm reports.

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COVID-19 which had its outbreak in late 2019 in China’s region, Wuhan, quickly spread across the globe affecting thousands and leading to the deaths of many. The World Health Organization (WHO) declared it to be a global pandemic in March of 2020, and although multiple reports of research being carried out to prevent the virus contraction came forward, the virus continues to spread in the countries as per latest reports.

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The United States, England, Italy, Spain, Iran, India, and Pakistan are some notable countries drastically affected by the novel virus. Experts estimate that a potential vaccine could be available in the next 12 to 15 months but no concrete evidence guarantees the vaccine at the moment. Simultaneously, cases have greatly spiked across South-Asian states including Pakistan and India since late May and early June. It is estimated that almost 670,000 people were affected by the virus in Punjab alone, approximately two weeks prior to Eid.

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Recently, clinical management guidelines to combat COVID-19 have surfaced as shared by one of Pakistan’s leading doctors, heading the fight against the novel virus, in the country.

According to reports, the provided ‘recommendations are being regularly reviewed by the Ministry of National Health Services, Regulations & Coordination and will be updated based on the international & national recommendations and best practices’, respectively.

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According to reports of Baaghi TV, these guidelines have classified the management of the virus on basis of its severity. The severity of the disease helps medical experts to distinguish the need for treatment, categorized as follows:

Asymptomatic
Mild disease
Moderate disease
Severe disease
Critical disease

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Asymptomatic:

This is the first tier. Cases belonging to this disease severity are considered to be infected with the SARS CoV 2, however, they show no symptoms and are advised to manage the disease within their homes, by following the WHO guidelines to combat the disease. These management guidelines may include leaving the house when absolutely necessary, taking precautions, washing hands regularly and maintaining proper hydration.

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Mild Disease:

The second tier is classified as a mild case of the viral infection. This group experiences a presence of symptoms that are believed to be consistent with COVID-19 but without any ‘hemodynamic compromise’ that is, need for oxygen. They also do not need any chest X-rays for treatment.

This group is advised to stay at home, or to shift to an isolation ward, in case they cannot have proper arrangements at home. Doctors suggest that they also follow home management guidelines including:

All supportive care with paracetamol for fever, ORS for diarrhoea and antihistamines for rhinorrhea.
NO specific treatment.
For any warning signs call 1700/1122 for assistance and guidance or consult health care facility.

Such patients experience symptoms of cough, fever, shortness of breath, asthenia/lethargy, chills, muscle pain, headache, sore throat, new loss of taste or smell, respectively.

Experts believe that patients belonging to this tier can consider the following to be warning signs for their condition:

Fever > 7 days or new fever after initial defervesce
SOB exertion or RR>20
SpO2 of <94% on room air
Persistent palpitations
Pleuritic /Chest pain
Haemoptysis
New confusion/lethargy
Severe diarrhoea and dehydration
Excessive vomiting

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Moderate Disease:

These cases are expected to isolate in hospital units. As they require being equipped with all routine items in a medical facility as well as proper Oxygen supply mechanism which can be delivered at up to 10 lit/min, as well as an oximeter.

People at this stage further require supportive care and investigations such as:

Oxygen through a face mask, nasal cannula
Voluntary prone positioning
If already on anticoagulation continue the same if not start on standard DVT prophylaxis (enoxaparin 40mg OD)
Remedesivir4 Moderate and severe COVID requiring oxygen therapy regardless of if CRS is present. Use in critical patients as per available data is unlikely to be of benefit.
In case of Cytokine release storm2 : a) Steroids 0.5-1 mg/kg/d of methylprednisolone for 5 days. Avoid if no evidence of CRS. b) Tocilizumab3 Is reserved for patients in whom worsening occurs despite steroids or those who present as severe/critical disease in CRS.

Experts believe that cases belonging to the moderate or above category need to be assessed for:

cytokine storm
CBC
Ferritin
C-Reactive Protein
Lactate Dehydrogenase
D-Dimer
Chest X-ray (PA view)

They may also be assessed for optional investigations, including:

Procalcitonin
Troponin
Echo
Pro-BNP
IL-6
CT scan Chest

In certain cases, patients may also need to be assessed for:

Liver Function tests
BUN creatinine and electrolytes
Blood cultures
Blood glucose levels
EKG
ABG (for severe and critical)
Serum lactate (for severe and critical)
Respiratory cultures (for severe and critical)

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Severe Disease:

Adults belonging to this disease severity, tend to exhibit signs of pneumonia such as fever and cough, along with any of the following:

Respiratory Rate >30
Severe respiratory distress
SpO2≤90 on room air
Chest X-ray involving >50% of lung fields

They are considered to be a ‘High Dependency Unit’ (HDU) and need to ‘well ventilated’ as well as equipped with ICU where the Oxygen is supplied to them from a central source and the delivery systems are; High flow nasal cannula, CPAP, BiPAP, (NIV), The monitor and bed, along with other supplies are similar to ICU.

Moreover, they require supportive care such as:

Oxygen through High flow Nasal Cannula, CPAP (NIV)
Prone positioning for 12-15 hours
Anticoagulation: Switch to parenteral anticoagulation as aggressive prophylaxis dose as enoxaparin 40 mg q12h , if D-Dimers >3 times normal give therapeutic dose enoxaparin 1mg/kg/q12h
Antibiotics only on specific indication, send cultures
Remedesivir
Moderate and severe COVID requiring oxygen therapy regardless of if CRS is present. Use in critical patients as per available data is unlikely to be of benefit.
In case of Cytokine release storm:

c) Steroids 0.5-1 mg/kg/d of methylprednisolone for 5 days. Avoid if no evidence of CRS.

d) Tocilizumab Is reserved for patients in whom worsening occurs despite steroids or those who present as severe/critical disease in CRS.

Cytokine Release Storm (CRS)

Any of the following in the presence of moderate, severe or critical disease:

1. Ferritin>1000 mcg/L and rising in last 24 hours.

2. Ferritin>2000 mcg/L in patient requiring high flow oxygen or ventilation.

3. Lymphopenia <800 cell/ml, or lymphocyte % ><20%, or Neutrophil to Lymphocyte ratio of >5 and TWO of the following.

Ferritin >700 mcg/mL and rising in the last 24 hours.

LDH >300 IU and rising in the last 24 hours.

D-Dimer>1000ng/ml(or>1mcg/ml) and rising in the last 24 hours.

CRP>70 mg/L(or >10 hs CRP) and rising in the last 24 hours, in absence of bacterial infection.

If any 3 present on admission no need to document rise.

Tocilizumab dose

4-8 mg/kg IV. Not over 800mg (max), can repeat after 12 hours once only.

Contraindications

Active TB, Zoster, Sepsis and positive blood culture, suspected GI perforation, Multiple sclerosis, allergy to Toci, ALT>5 Times or Bilirubin>2, ANC<2000 or Thrombocytopenia ><50k, Pregnancy(relative contraindication) 4: Remdesivir · 200mg IV on day 1 followed by 100mg IV daily on day 2-5><2000 or Thrombocytopenia <50k, Pregnancy (relative contraindication).

Remdesivir

200mg IV on day 1 followed by 100mg IV daily on day 2-5

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Critical Disease:

Cases falling in this category can have any of the three manifestations

ARDS5
Multiorgan dysfunction
Septic shock

These patients are admitted in the Intensive Care Unit as they need to be well ventilated and equipped with an ICU bed, a ventilator, a cardiac monitor, infusion pumps, and other items as per basic needs, respectively.

They also need supportive care such as:

Oxygen through mechanical ventilation.
Prone positioning for 12-15 hours.
Anticoagulation: Switch to parenteral anticoagulation as aggressive prophylaxis dose as enoxaparin 40 mg q12h , if D-Dimers >3 times normal give therapeutic dose enoxaparin 1mg/kg/q12h.
Antibiotics only on specific indication, send cultures.
Remedesivir Use in critical patients as per available data is unlikely to be of any benefit.
In case of Cytokine release storm2 : e) Steroids 0.5-1 mg/kg/d of methylprednisolone for 5 days. Avoid if no evidence of CRS. f) Tocilizumab Is reserved for patients in whom worsening occurs despite steroids or those who present as severe/critical disease in CRS.

ARDS

Onset: within one week of a known clinical insult (pneumonia) or new or worsening respiratory symptoms.
Chest Imaging: (X-ray or CT-Scan): Bilateral opacities, not fully explained by volume overload, lobar or lung collapse or nodules.
Origin of pulmonary infiltrates: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography to exclude hydrostatic cause of infiltrates /edema if no risk factor present.
Oxygen impairment in adults
Mild ARDS : PaO2/FiO2:>200 mmHg and ≤ 300 mmHg (with PEEP or CPAP≥5cm H20
Moderate ARDS: PaO2/FiO2:≤200 mmHg and > 100 mmHg (with PEEP or CPAP≥5cm H20
Severe ARDS: PaO2/FiO2 ≤100 mmHg (with PEEP ≥cmH20)

Multiorgan failure

Acute life threatening organ dysfunction caused by a dysregulated host response to suspected or proven viral or bacterial infection.
Signs of organs dysfunction include: Altered mental status, difficult or fast breathing, low oxygen saturation , reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

Septic shock

Persistent hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥ 65 mmHg and serum lactate level > 2 mmol/L.

It is to be noted that, the COVID-19 Health Advisory Platform by Ministry of National Health in Pakistan estimates, that there are 80,463 confirmed cases in Pakistan. So far, 49,852 active cases, while 1,688 people are reported to have died from it till date.

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