949:  Round Table Expert Zoom Meeting on “Triggers of sudden deterioration in COVID patients”

 13^th June, 2020, 11am-12pm

Participants: Dr KK Aggarwal (Chair); Dr AK Agarwal; Dr Girdhar Gyani; Dr Ashok Gupta; Dr DR Rai; Dr JA Jayalal; Dr Jayakrishnan Alapet; Dr PN Arora; Dr N Kamat; Mrs Upasana Arora; Mr Bejon Misra; Ms Meenakshi Datta Ghosh; Dr K Kalra; Ms Ira Gupta; Dr Sanchita Sharma

This webinar was dedicated to Mr Sanjay Sharma, Asst. Manager - IT & Election Work, Indian Medical Association (IMA), who passed away due to COVID-19.

 Key discussion point: Can death in COVID patients be prevented if trigger/s can be identified?

 Timely detection of hypoxia can prevent death

The first trigger is silent hypoxia or “happy hypoxia”. It appears more when fever subsides (between Day 7 to 9). It may occur in patients who have no comorbid conditions.

Normally, in hypoxia, carbon dioxide levels are raised and the person is irritable. In hypoxia in COVID patients, the carbon dioxide level is normal, lung elasticity is normal. In these patients, microvasculitis occurs in lungs, microclots are formed due to vascular endothelial dysfunction with resultant intussusception of the artery, i.e., the artery is partially thrombosed and partially patent, so perfusion is maintained.

2. If SpO₂ level falls more than 4 on talking or walking, this is the first sign of hypoxia. 

Once the trigger is known, it is time to act. Before beginning the search for a hospital bed, give: One dose of antiviral (remdesivir if available), one dose of LMWH, water-soluble aspirin stat and start home oxygen therapy before shifting to a hospital.

3. Do a hemogram, CRP, LDH, D-dimer along with RT PCR

 If at the time of diagnosis, lymphocyte count, CRP (<10) and ESR are normal, the disease is most likely to be self-limiting.

Raised ESR, CRP levels are indicative of inflammation in the body. Patients with high ESR, CRP (>26), ferritin and D-dimer levels are at high risk for severe illness.

At the time of diagnosis:

• If lymphocyte count is <1000:  Admit the patient
• If progressive lymphopenia (<800) with rising LDH: Admit the patient in ICU
• If lymphocyte count is >1000: non-severe illness

Give first dose of LMWH if there is progressive rise in D-dimer levels.

4. Loss of smell and taste: Around 20% of patients develop loss of smell and taste. Sweet and salt taste are lost, sour and bitter are retained. They are indicative of less severe illness with less chance of complications.
5. If a patient has diarrhea, he/she is more contagious and may have higher viral load. May be the super spreader.
6. Assurance and relief of anxiety is important. Cellular stress can lead to inflammatory reaction in the body, which can precipitate microthrombi.
7. If baseline X-ray chest shows two opacities- admit; 3 opacities - likely to go for high flow oxygen.
8. On the 9^thday, the person is recovered, not cured. The virus becomes non-infectious. After 10^th day, self-quarantine for one week.

9. If fever >103^oF persists for more than 2 weeks, look for precipitation of underlying immunological disease.

10. Give LMW heparin prophylactically to all elderly and high risk individuals with comorbidity.

We also need to find solutions for triggers. Ensure availability of oxygen across all hospitals (tertiary, secondary and primary).

Now focus should be on arranging oxygen concentrators, oximeters even in housing societies, residential apartments, so that triggers can be identified early. One apartment in residential areas can be identified and prepared. A suggestion can be made to the government in this regard.

A suggestion was made that the government should be asked to publish a study analyzing clinical presentation and treatment given to COVID patients in the country.

Multiple Corona positive patients from a colony can stay together. This is called Cohort isolation.

Not just the general public, healthcare workers too are facing high anxiety and stress levels. They should be motivated. We also need to talk to hospital administrators.

There is anxiety among surgeons that should they operate? All doctors should assess their risk.

A suggestion was put forth during the discussion about creating a platform, with ethical clearance to interact with patients, which can then become a scientific literature for doctors.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA