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.
