treatment guide

https://www.evms.edu/media/evms_public/departments/internal_medicine/EVMS_Critical_Care_COVID-19_Protocol.pdf 

Page 9 was interesting

Scientific Rational for Treatment Protocol Three core pathologic processes lead to multi-organ failure and death in COVID-19: 1) Hyper-inflammation (“Cytokine storm”) – a dysregulated immune system whose cells infiltrate and damage multiple organs, namely the lungs, kidneys, and heart. It is now widely accepted that SARS-CoV-2 causes aberrant T lymphocyte activation resulting in a “cytokine storm.”. 2) Hyper-coagulability (increased clotting) – the dysregulated immune system damages the endothelium and activates blood clotting, causing the formation of micro and macro blood clots. These blood clots impair blood flow. 3) Severe Hypoxemia (low blood oxygen levels) –lung inflammation caused by the cytokine storm, together with microthrombosis in the pulmonary circulation severely impairs oxygen absorption resulting in oxygenation failure. The above pathologies are not novel, although the combined severity in COVID-19 disease is considerable. Our long-standing and more recent experiences show consistently successful treatment if traditional therapeutic principles of early and aggressive intervention is achieved, before the onset of advanced organ failure. It is our collective opinion that the historically high levels of morbidity and mortality from COVID-19 is due to a single factor: the widespread and inappropriate reluctance amongst intensivists to employ anti-inflammatory and anticoagulant treatments, including corticosteroid therapy early in the course of a patient’s hospitalization. It is essential to recognize that it is not the virus that is killing the patient, rather it is the patient’s overactive immune system. The flames of the “cytokine fire” are out of control and need to be extinguished. Providing supportive care (with ventilators that themselves stoke the fire) and waiting for the cytokine fire to burn itself out simply does not work… this approach has FAILED and has led to the death of tens of thousands of patients. The systematic failure of critical care systems to adopt corticosteroid therapy resulted from the published recommendations against corticosteroids use by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the American Thoracic Society (ATS) amongst others. A very recent publication by the Society of Critical Care Medicine and authored one of the members of our group (UM), identified the errors made by these organizations in their analyses of corticosteroid studies based on the findings of the SARS and H1N1 pandemics. Their erroneous recommendation to avoid corticosteroids in the treatment of COVID-19 has led to the development of myriad organ failures which have overwhelmed critical care systems across the world. Our treatment protocol targeting these key pathologies has achieved near uniform success, if begun within 6 hours of a COVID19 patient presenting with shortness of breath or needing ≥ 4L/min of oxygen. If such early initiation of treatment could be systematically achieved, the need for mechanical ventilators and ICU beds will decrease dramatically. It is important to recognize that “COVID-19 pneumonia” does not cause ARDS. These patients have normal lung compliance with near normal lung water (as measured by transpulmonary thermodilution). Treating them with early intubation and the ARDNSnet treatment protocol will cause the disease you are trying to prevent i.e. ARDS. These patients tolerate hypoxia remarkable well, without an increase in blood lactate concentration nor a fall in central venous oxygen saturation. We therefore suggest the liberal us of HFNC, with frequent patient repositioning (proning) and the acceptance of “permissive hypoxemia”. However, this approach entails close patient observation.