COVID 19 PNEUMONIA

58yrs old female history of one dose covishield vaccination in march month started illness from 28/04/2021 with fever , cough , gradually develop fatigue , loss of appetite . H/o hypertension but not on regular treatment,on 03/05/2021 checked her saturation about 80% but no SOB....Admited to district gov hospital on 04/05/2021 but saturation not improved and gradually SOB develop CTSS is 19/25 so reffered to medical college where i am working . Admited to medical college on 05/05/2021 and put on NRBM mask with 10LPM o2 flow....started treatment for severe covid19 as per protocol ...CRP >80 So methylprednisolone 500 mg for 3 day pulse therapy given and after tha dexamethasone 2cc iv od started ABG on 07/05/2021 Pao2/Fio2 > 300 ....everything is on track but on 15/05/2021 she increase SOB, increase o2 requirment and tachycardia ABG done Pao2/Fio2 < 100 so put on NIV/PCV wth PEEP =6 Pins 12 Fio2 80% gradually PEEP requirment and Pins is increse to maintain spo2 90 % to 10 and 16 ....on 23/05/2021 HRCT finding s/o CTSS 25/25 ARDS, cardiomegaly and fungal ball in left upper lobe....added voriconazole... Last lab parameter on 28/05/2021 crp =28 d-dimer = 0.5 IL6= 2 normal TLC , normal RFT, LFT and electrolyte ..since 2 day i tried to wean off NIV but not succeed....today setting is Fi02 80% Pins 10 Peep 6 RR 40 .... Kindly give advise how i wean this pt from ventilator ...increasing PEEP and Pins is not working....Fio2 reduction cause fall in saturation Kindly advise what should be doing to wean off pt and advise for further care of this patient..

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A case of post covid - 19 vaccination flare up of severe Covid-19 viral pneumonia. As a,very high dose of steroids were,given which have resulted in fungal ball left upper lobe .Although high dose steroids have increased saturation but the CTSS,increased from 19 / 25 to 25 / 25 due to associated pulmonary fungal infection .A lower dose of steroids should have been given. Right now - it will be difficult to wean off NIV considering associated pulmonary fibrosis which must have occurred by now . Now treatment options are Inj Dexamethasone 4 mg / day Antifibrotic agents like Pirfenidone or nintedanib Oral anticoagulants like Dabigatran 1110 mg Tab cefuroxime 500 mg B.D for 10 days Posiconazole Continue oxygen support and remaining treatment

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A complicated case of severe Covid related pneumonitis with associated fungal ball formation due to steroid induced immunosuppression... Steroids again the culprit....no indication of pulse therapy in any guidelines.... Take Anesthesiologist opinion.... PaO2/FiO2 <100 indicative of ARDS, a rare but reported occurence in severe covid pneumonitis.... A dedicated ICU planwork with team of experienced intensivists is req but prognosis remains grave

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As all lab parameters are almost normal,pt is not maintaing saturation on NIV with FiO2 80% and peep 6 The best thing is to Prone position Increase FiO2 to 100 Increase Peep above Ps to 20 Don't increase Peep Inj h cort 200 mg stat after that inj hcort 100 mg BD Inj dexametadin 5 amp in 50 ml NS @ 5 ml /hr Inj midaz 1 ml iv BD Inj vecronium 5 ml in 50 ml NS iv @ 5 ml/h Don't wean off pt right now,it will take time If still no improvement then intubate pt

Valuable opinion
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Post covid vaccination flareup of covid19 pneumonitis Treated well under ICMR protocols Pt droping saturation despite good oxygenation as hrct shows fungal ball rt apex which developed after hospitalization You choose voricanazole better should have gone for inj amphotercinB liposomal now difficult to shift on as contraindicated Try other two anti fungals isopcanazole posicanazole probably spellings may be mistaken so correct them If available try 2degee granules Or cocktail injection With continuous 02 support

Thank you doctor
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Rx Fabiflu 800 Doxycycline 200mg 1BD Ivermectin 12mg 1OD Dolo 650 mg1BD Nebulization TDS Aptimust syrup Vit B complex, Vit C and Zinc

Main question about how to weaning off?
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Just simply apply Iv pipercillin 4.5g every 8hrs Iv Dexa bd

Will you like to provide Ayurvedic medicines with running medication.

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