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CMAAO Coronavirus Facts And Myth Buster: COVID Update – Pulse oximeters; Steroids

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Dr KK Aggarwal    23 December 2020

With input from Dr Monica Vasudev

  1. Pulse oximeters have 3-fold higher odds of missing oxygen starvation in Blacks as compared to whites.
  2. Among 1,609 patients treated earlier this year at the University of Michigan Hospital, in Ann Arbor, 11.7% of Blacks were found to have an alarming arterial oxygen saturation of <88%, measured directly in the blood, despite their pulse oximetry levels showing the normal range of 92% to 96%. The devices, originally designed for people with light skin, missed low oxygen levels in only 3.6% of whites, which represented a statistically significant difference.
  3. When investigators assessed data from 8,392 other patients treated at 178 intensive-care units during 2014 and 2015, pulse oximeters appeared to miss low blood oxygen levels in 17.0% of Black patients compared to 6.2% of whites; again a significant difference.
  4. Dr. Michael Sjoding of the University of Michigan Medical School, and colleagues noted that reliance on pulse oximetry to triage patients and adjust supplemental oxygen levels may place Black patients at an escalated risk for hypoxemia. The analysis is published in the New England Journal of Medicine.
  5. The devices make use of red and infrared light to gauge the color of hemoglobin, which darkens to purple-red as the oxygen levels decline. Since pulse oximeters were mostly tested on whites when they were developed, they are calibrated for light skinned individuals.
  6. The racial discrepancy was evident even after the investigators excluded people with diabetes and elevated carboxyhemoglobin levels. (SOURCE: Medscape)

1238: Steroids the Go-To Standard for COVID

  1. One year into the COVID-19 pandemic, hospital physicians say that the most reliable drug for the illness is cheap, familiar dexamethasone.
  2. The side effect profile, the risks, and the benefit are known.
  3. Dexamethasone shows more benefit than drugs like remdesivir and convalescent plasma.
  4. In the early days of the pandemic, there was a lot of hue and cry about steroids because there was literature from SARS and MERS stating that patients who got steroids had higher viral loads.
  5. In those disorders, steroids appeared to make the virus replicate more or delay the immune response to clear it.
  6. Steroids had previously shown value in treatment for ARDS, while other drugs such as hydroxychloroquine werent helping. So, the course was changed, steroids were administered and there was a significant impact.
  7. An influential study published in the New England Journal of Medicine in July supported the use of dexamethasone. The 28-day mortality was found to be reduced among patients on oxygen alone (23.3% vs 26.2% with standard care; RR 0.82; 95% CI 0.72-0.94) or a mechanical ventilator (29.3% vs 41.4%; RR 0.64; 95% CI 0.51-0.81).
  8. Death rates were higher when the drug was given before oxygen supplementation relative to standard care (17.8% vs 14.0%; RR 1.19; 95% CI 0.91-1.55).
  9. Looking at the treatments available for COVID -- remdesivir, convalescent plasma, dexamethasone -- the only one shown to have a mortality benefit is dexamethasone
  10. Remdesivir reduces hospital length of stay, but doesnt affect morality.
  11. The National Institutes of Healths guidelines about steroids and COVID note that "if dexamethasone is not available, alternative glucocorticoids such as prednisone, methylprednisolone, or hydrocortisone can be used."
  12. If started too early, theyll dampen the immune system when it needs to be strong.
  13. Starting them too late can miss the period when the body is overreacting and causing havoc in the lungs.
  14. Some patients with underlying disorders, such asthma and COPD, may already be receiving steroids before they need oxygen therapy, and should get their doses increased. COVID can incite reactivation of herpes simplex virus and cytomegalovirus. Steroids must be used carefully in patients with these disorders.
  15. At the University of Minnesota, the protocol is to start dexamethasone in COVID-positive patients who are hypoxic (<90% on room air) and stop it when the patient is no longer hypoxic or at discharge.
  16. According to the NIH, dexamethasone should be continued for up to 10 days or until hospital discharge, whichever comes first.
  17. A benefit is seen within the first 3-4 days. Maybe reevaluate 4-5 days in.
  18. Steroid-induced psychosis or altered mental status is quite common, particualrly in older adults.
  19. If it occurs, consider reducing the dose and making their daily routine as similar to normal as possible – awake in daytime and asleep at nighttime. Other medications can be tried as needed.
  20. Steroid-induced psychosis can resemble hospital delirium -- people become hyperactive, are unable to sleep, and have altered mental status. Differentiating these two phenomena can be difficult.
  21. A study in Chile, expected to be completed this month, evaluates whether treatment with prednisone will help patients with mild disease avoid exacerbation. (SOURCE: Medpage Today)

 

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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