Since the discovery of Covid 19(Coronavirus SARS COV 2) in December 2019, flow of information and circumstances are changing everyday. It is hard to keep up with so much information and sort out real from myths.
- Unusually high sedation requirements in large proportion of COVID-19 patients.
- Need to administer combinations of multiple agents (e.g., propofol, ketamine, hydromorphone, dexmedetomidine, midazolam), increasing potential risks of side effects (e.g. QT prolongation, hypertriglyceridemia, hypotension, delirium)
- Deeper sedation levels may be required to facilitate ventilator synchrony
- Intermittent administration of certain drugs (e.g. narcotics) may not be feasible for protection of healthcare workers.
- A subset of patients with severe ARDS is likely to require prolonged sedation (oftentimes >2
- Increased precision in monitoring the depth of sedation (e.g. processed EEG) is required
- High doses of opioids may trigger large tidal volumes, paradoxically.
- Drug shortages have been reported, which leads to use of less commonly used agents (barbiturates, methadone, clonidine,
chlorpromazine, propranolol) . The use of inhalational anesthetics (e.g. isoflurane), at least in locations with appropriately designed scavenging systems
- Potential interaction between sedative drugs and other agents
Here is a short and sweet summary from Massachusetts General Hospital to take care of Covid 19 patient. Mortality for those who required mechanical ventilation was 35.7% reported in one study.
A quick guide to code blue
In general, following points are important to remember which are referenced from reputable sources
- At present there is no cure and no prophylactic agent available. Several agents are being tried in various clinical trials worldwide. These include hydroxychloroquine(so far proven to not work), azithromycin, various antivirals include colchicine and tolicizumab.
- A retrospective case-controlled study showed benefit of convalescent plasma.
- Remdesivir has been shown to shorten duration of illness in a trial conducted by NIH, and there is a trend towards improved mortality, but not statistically significant. However, another trial published in Lancet showed no benefit.
- A comparative study from New York shows that full dose anticoagulation may improve survival in COVID patients.
- Social distancing can reduce the rate of spread, thereby preventing over burdening the hospitals, thereby reducing the mortality.
- Virus can survive up to 17 days on fomites.
- Ideal personal protective equipment is the one shown by Chinese, covering head to toe.
- Basic infection control measures still work, such as handwashing.
- There are up to 30% false negative test results. New antibody tests have come in to the market but several experts warn about their validity. FDA has recently taken half of the tests off market.
- Significant number of infected patients are asymptomatic. Interestingly, one study from Germany, other from Iceland showed 15% population was infected, mostly had no symptoms.
- Mortality rates are much lower than 3.4% as reported by WHO.
Best resource to track new patients
Best evidence for health care workers
A useful guide from New York.
A detailed review of COVID 19 by our friend Dr Nadyala
I will update this page as more information is available.