Wednesday, March 18, 2020

Should doctors prefer thrombolysis over primary PCI in COVID 19 patients with acute heart attack

Should doctors prefer thrombolysis over primary PCI in COVID 19 patients with acute heart attack
How to handle dialysis in covid 19 positive cases

Dr KK Aggarwal
President CMAAO, HCFI and Past National President IMA

New challenges can lead to new rules, or at least new protocols based on the best available data.

Excerpts from Medscape Articles: The authors argues against a "thrombolysis first" approach to treating acute heart attack followed in China. But ACC/SCAI statement proposes that fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19, after careful consideration of possible patient benefit vs the risks of cath-lab personnel exposure to the virus.

Patients with STEMI or with NSTEMI and symptoms or compromised hemodynamics should be taken to the cath lab for angiography/primary PC. Post-transfer patients who have received fibrinolysis should still be taken for rescue PCI if clinically appropriate.

Follow following approach : Society for Cardiovascular Angiography and Interventions (JACC)

1.     Confirmed COVID-19 infections: For STEMI or NSTEMI, send patients to the cath lab for angiography and, as appropriate, PCI; in stable NSTEMI, "medical management with coronary angiography for recalcitrant symptoms only may be the most logical approach."
2.      Possible COVID-19 infection: In STEMI, treat with primary PCI. In NSTEMI, "await coronary angiography until a negative COVID-19 test has been obtained."
3.      Elective cath procedures: "This group of patients requires an approach that is evolving,". As most of them will have structural heart or peripheral vascular disease, for now "these patients should probably not undergo elective procedures until we have better assessment of the situation over the next few weeks."
4.      The ACC/SCAI document notes that many centers have already suspended elective cath procedures. "This certainly seems prudent in locales where the disease is highly prevalent," it states.
5.      "Under any circumstance, to preserve hospital bed capacity, it would seem reasonable to avoid elective procedures on patients with significant comorbidities or in whom the expected length of stay is >1 to 2 days (or anticipated to require the intensive care unit)."
6.      The recommendations may change rapidly "depending on the overall critical care and inpatient service burden, especially as we continue to follow the growth trajectory of COVID-19 infections,"
7.      "You will have to work with your local institutions and administration to determine the best way to approach these decisions in concert with [Centers for Disease Control and Prevention] guidelines, and both infectious disease experts and critical care intensivists."

Dialysis in COVID 19 patients
CDC: The  guiding principle is first and foremost to make sure patients are coming to dialysis.

For patients, efforts should be made to identify those with signs and symptoms of respiratory infection, such as fever and/or cough, before they even enter the treatment area, the guidelines recommend. Measures should include:

1.     Instructing patients to call ahead to report fever or respiratory symptoms so the center can be prepared for their arrival or to triage to a more appropriate setting, such as an acute care hospital.
2.      Patients should be asked to inform staff of fever or respiratory problems immediately upon arrival at the facility.
3.      Those with symptoms of a respiratory infection should be provided with a facemask at check-in and instructed to wear it until their departure.
4.      In addition, all patients and healthcare personnel should be instructed, in appropriate languages, about hand hygiene, respiratory hygiene, and cough etiquette, including instruction on how to use facemasks and tissues to cover nose and mouth when coughing, and proper disposal of tissues and contaminated items
5.      And signs should be posted throughout dialysis facilities reminding patients to inform staff of fever or symptoms of respiratory infection.
6.      Supplies for hand and respiratory hygiene and information about cough etiquette should be placed in close proximity to dialysis chairs and nursing stations.
7.      For medically stable patients facilities give the option of waiting in a personal vehicle or outside the facility and to be contacted by mobile phone when they are ready to be seen.
8.      Dialysis facilities should have space allocated to allow patients who are ill to sit separately from other patients by at least 6 feet.
9.      Patients experiencing respiratory symptoms should promptly be taken to appropriate treatment areas to reduce time in waiting areas.
10.   For those with symptoms, ideally, dialysis treatment should be provided in a separate room from other patients, with the door closed.
11.   If a separate room is not available, the masked patient should be treated at a corner or end-of-row station not near the main traffic flow. A separation of at least 6 feet should be maintained between masked, symptomatic patients and other patients during treatment.
12.   Use of hepatitis B isolation rooms should only be considered for patients with respiratory symptoms if the patient has hepatitis B or if no patients treated at the facility have hepatitis B.
13.   Healthcare personnel caring for patients with undiagnosed respiratory infections should further observe standard contact and droplet precautions with eye protection unless a suspected diagnosis such as tuberculosis requires airborne precautions

14.  Precautions should include using gloves, facemasks, eye protection, and isolation gowns.

15.  Should a facility have more than one patient with suspected or confirmed COVID-19, the center should consider cohorting or grouping these patients and the healthcare personnel caring for them together in the same section of the unit and/or on the same shift, such as the last shift of the day. However, if patients with respiratory symptoms have different etiologies, cohorting is not recommended.

16.  Routine cleaning and disinfection for COVID-19 are appropriate in dialysis settings. All surfaces, supplies, or equipment located within 6 feet of symptomatic patients should be disinfected or discarded.

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