COVID Survivor
Know a patient who is a COVID survivor. He was in the ICU for a month, requiring mechanical ventilation for almost four weeks. That’s much longer than a typical patient with bacterial pneumonia. This patient required a lengthy infusion of the neuromuscular blockade which, along with shock, contributed to the profound weakness. This complication is also called critical illness polyneuropathy. *What can we do during these 4 weeks when the patient is paralyzed to minimize the myopathy and neuropathy that may develop? *Are there treatments or therapies? *Are you familiar with the concept of Disease tolerance and Adaptogens? I’d love to hear others’ reflections on this and if you have any tips for preparation
Thanks @DrSushil Mehra for initiating the discussion on critical illness polyneuropathy and myopathy in patients on prolonged mechanical ventilation.. We can take certain measures to reduce the incidence during ICU care a d after discharge from hospital. But in Indian set up difficult to execute because of mind set .But doctors on curofy can resolve to put it into practice. 1.Early mobilization and early weaning off ventilator should be encouraged. 2.Use of specialized beds which continuously turn patients along the longitudinal axis up to 60 degree on each side with pre- set degree and speed of rotation. Prestigious institutes can use such beds in ICU- as these are already in use in Wuhan and other countries. 3.Prone position during mechanical ventilation should be used particularly in respiratory conditions like ARDS , viral pneumonia which not only improves PaO2 / FiO2 , but also reduces myopathy. 4.Passive limb exercises and passive pneumatic compressions in such patients on ventilatory support will reduce myopathy and polyneuropathy . 5.Neuromuscular electrical stimulation in ICU in lower limb muscles have some benefits. 6 Once patient is discharged as in your patients case- medications which I have found useful in clinical practice for myopathy are tab Go - Cram or Cramnil containing magnesium bisglycinate 360 mg B.D - as magnesium deficiency is seen in such patients. Addition of L - carnitine 500 mg B.D and CO- Q- 10 B.D gives dramatic results besides O.R.S . Disease tolerance concept should not be confused with resistance or immune tolerance. Disease tolerance protects by promoting host health while having positive effect on pathogen illness .Innate immunity or herd immunity does increase disease tolerance. Environmental factors play most important role - particularly increased gut microbiotica ( Use of pre- probiotics) have now been considered for increasing host tolerance. T- cell exhaustion as in this case do help in host tolerance. Adaptogens - may increase resistance to physical and mental stress to chronic illness .Most popular adaptogen being used is Ginseng and other herbal products. These are used in Russia , Korea and china .Ot late in india Patanjali products like Giloy Ghanvati , Aloe vera juice , amla juice are increasingly used as adaptogens .But adaptogens have not been approved in pharmacology and clinical practice settings and further studies are needed to get official approval
Premature discussion ,we are not guided be guildlines issued by various authorities from time to time. We may discuss about various aspect of sing ,symptoms and treatment part of COVID 19 but few of our colleagues are in vary tight spot who make experiment under current situation on human life .so it good for discussion ,pl don't make management chart or experiment on precious human life.follow line of management as directed by Govt / WHO or any other competent authority issued or briefed everyday .
Usual period recommended for ventilatory support is 2 weeks. Critical illness neuropathy and Myopathy is not documented on COVOD 19. GBS is already documented after the recovery of COVID 19. NeedsNCV to exclude GBS ,if not done better to do. For critical illness neuropathy & myopathy as you know preventive and supportive care only reported.
It’s still an infant,we don’t know how it’s behaving & we depending upon each institution inputs. All management r dictated by Govt./ AIIMS/WHO Guidelines. In my opinion we can use the drugs,whatever available to us in trial basis or empirical therapy, unless strict guidelines comes to the force.( my personal view)
Critical illnes neuropathy or myopathy had poor out come and one of the cause of prolong ventilator support and delayed weaning off from ventilation...there is no proper treatment of both only strictly rbs control is required And should be rouled out other causes of neuropathy and myopathy with ncv and emg
As inputs came related to IL6 As this looks to immunity suppressant Interlukins may be choice
Was that supported by ncv,emg ,in addition what were the antibiotics given to him & was there any bacterial supper added infection ,did the pt have pseudo cholinesterase deficiency , after all these considerations , one can think of critical illnesses neuropathy
Polyneuropathy have to be felt with lower dose of steroid and heavi dose of vit B1,B6andB12
Thanks Dr Mishra and Dr yograj for new lession in corona Good up date keep up in future also
Cases that would interest you
- Login to View the image
34yrs/M admitted with C/o Generalized bodyaches,3 day history of on and off fever which is temporarily relieved by paracetamol,Hypogastric pain,He also experienced nausea and vomitting with loss of appetite.NO PETECHIAE OR RASES present over body.He was tested negative for COVID 19 but positive for dengue.On day 2 admission patient developed dry cough and mild difficulty in breathing. NEED SUGGESTIONS? *Chief Complaints* Fever,bodyaches,NV, Abdomen pain *History* No relevant medical history *Vitals* BP - 120/80,HR -110,Temp -99°F,Spo2 -98% without O2 support,RR - 18 *Investigations* COVID - RT PCR - NEGATIVE DENGUE IGg - Positive Platelet counts -4000,Hb -12,TLC -12000 HRCT chest enclosed
Dr. Prashant Vedwan5 Likes19 Answers - Login to View the image
COVID-19?? 68 year old male with no significant past medical history or surgical history. Presented with shortness of breath, and chest pain. In the emergency department, the patient has a saturation of 79% on room air and is in Moderat respiratory distress. It requires 10 L of nasal oxygen high flow to obtain 93% oxygen saturation. The patient is also febrile to 101°F. Social history: non-smoker, non-drinker. Surgical history: no surgical history. What do you say about the case?
Dr. Shekhar Verma6 Likes41 Answers - Login to View the image
A 65 year old female presented to OPD with complaints of breathlesness and dry cough for last 3 days. She has tested negative for COVID 19 Antigen test report. Spo2 - 87% Pulse - 62/min BP - 100/70mmHg Kindly comment on line of management for such patient?
Dr. Ajeet Pal Singh4 Likes18 Answers - Login to View the image
x-ray chest of first case of Corona virus pneumonia patient aged 61 years male who died during treatment in WUHAN city of China.
Dr. Ramesh Dutt Gautam48 Likes41 Answers - Login to View the image
44-year-old male, stigmata of HIV, presented with shortness and respiratory distress. Patient was intimated and sedated. The patient is a known MDR-TB patient, on further investigation found to have completed treatment in 2015. Other history was not obtained. On arrival patient x/ray reviewed (attached - Image 1) and bilateral infiltrates noted as well as ? right lung mass. The patient sent for urgent non-contrast CTB (NAD) and chest. CT findings: ‘Basal infiltrates bilaterally, no cavities, faint effusions with no gross adenopathy. Active TB is very unlikely. Cardiomegaly with PAH. Paraseptal emphysema - mild degree only. Right pericardiac mass (mediastinal).” Patient management is ongoing. What are your valuable suggestions?
Dr. Akhil Sharma8 Likes36 Answers
9 Likes