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COVID Management Update

0.75 CME/MOC Available Listen to Podcast Log in for access

COVID Management Update

This podcast covers supportive care, oxygenation, labs, anticoagulation, medications, and recovery. 

STEP 1: Listen to the podcast

STEP 2 (Members Only): Take the CME/MOC Quiz

Show Notes

Part 1: Supportive Care

  • Care for COVID patients in the ICU is not different than care for other critically ill patients. It depends on data collection/interpretation and regimented decision-making.
  • Supportive care seems basic, but is one of the most important parts of caring for COVID patients.
  • The most important thing is to pay attention to their vital signs and think about basic needs of our patients - develop your differential diagnosis for things like hypotension, hypoxia, and tachycardia so that you can appropriately evaluate and treat your patients.

Part 2a: Oxygenation

  • Think in terms of a step-up approach to oxygenation - self proning, supplemental oxygen, noninvasive positive pressure, and mechanical ventilation.
  • Self proning benefits patients in a few ways - decreasing V/Q mismatch, recruiting dependent lung segments, better drainage of secretions, improved hemodynamics. Most importantly, patients feel better!
    • Supplemental oxygen means everything from nasal cannula to face mask.
  • High flow nasal cannula is mostly supplemental O2 with a small amount of positive pressure.
  • Noninvasive positive pressure ventilation - usually referred to by the trade name of BiPAP - can be used with reasonable infection control. We were worried about this at the beginning of the pandemic, but can be done safely with precautions taken.
  • It’s ok to tolerate permissive hypoxemia if you can stave off intubating patients.
  • Intubation doesn’t just mean mechanical ventilation - it also means sedation, immobilization, infection risk.
  • The duration of mechanical ventilation can approach two weeks with a long tail.

Part 2b: Labs

  • Trending daily CRP, ESR, D-dimer, troponin, LDH, etc. probably doesn’t provide much useful information.
  • If you don’t know what you’re going to do with a test result - or don’t know what you’re looking for in the first place - it may be better not to order it.

Part 3: Anticoagulation

  • Anticoagulation has been a source of controversy throughout the pandemic.
    • There is observational data suggesting mortality benefit from full-dose anticoagulation in hospitalized patients.
    • Remember that observational data needs to be interpreted with caution - it is generally considered hypothesis-generating and not proof.
  • DVT prophylaxis is clearly appropriate.
  • Clinical vigilance for clots is also appropriate - think about DVT when a patient has unilateral lower extremity swelling or a PE with new tachycardia and hypoxia.
  • Critically ill patients can develop clots regardless of what makes them critically ill. It’s not clear that there’s something special about COVID that makes patients more hypercoagulable than other critically ill patients.

Part 4: Medications

  • RECOVERY trial demonstrated a clear mortality benefit from dexamethasone in severe COVID, particularly in ventilated patients.
    • Dexamethasone use for up to 10 days resulted in a lower 28-day mortality.
    • Benefit of steroids appears consistent across different trials and in a meta-analysis.
  • Remdesivir - a viral RNA polymerase inhibitor - seems to reduce time to recovery.
    • Remdesivir is best given early in course and a 5 day treatment duration is probably sufficient.
  • Hydroxychloroquine does not have a role in treating COVID.
  • IL-6 inhibitors, convalescent plasma, and other immunomodulators feel exciting, but we just don’t have any clear clinical benefit. Role for these treatments outside of clinical trials should be limited.
  • It is ok to continue ACE inhibitors or angiotensin receptor blockers. Indications for these medications don’t change just because someone has COVID and there is no need to stop them related to COVID risk. 

Part 5: Recovery

  • No one leaves the ICU the same as they entered. Long term effects in ICU survivors are common.
  • Post intensive care syndrome (PICS) can lead to significant long term morbidity.
  • Data on post COVID syndrome are heterogeneous and limited conclusions can be drawn, but clinicians should be aware that COVID patients may still be suffering after recovery from acute infection and hospital discharge.

Disclosures

Contributors

Greg Katz, MD - Host, Production

Martin Fried, MD - Host, Production

Laura Evans, MD, MSc - Guest Expert

Shreya Trivedi, MD - Producer

Reviewers

Avraham Cooper, MD

Nicholas Mark, MD*

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

*Dr. Mark reports stock options/holdings at CTI Biopharma where his spouse is employed. He reports previously being Principle Investigator of NIH and Barda Grants, and is a paid consultant for KenSci Inc. These relationships are not relevant to the content he is controlling

Release Date:  September 30, 2020

Expiration Date: September 30, 2023

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 0.75 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.

 

About Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.


Details

CME/MOC:

Up to 0.75 AMA PRA Category 1 Credits ™ and MOC Points
Expires September 23, 2023   active

Cost:

Free to Members

Format:

Podcasts and Audio Content

Product:

Core IM