Evaluating Hospitalized Patient
Evaluating Hospitalized Patient
The intent of evaluating hospitalized patients with documented or suspected COVID-19 pneumonia is to assess for markers associated with severe illness and determine organ dysfunction or other comorbidities that could complicate potential treatment (Kim & Gandhi, 2022). Based on the authors, initial laboratory tests include CBC w/ diff (daily) with a focus on the lymphocyte count trend, CMP (daily), CK, PT/PTT, D-dimer, Lactic acid (serial if elevated), Troponin (every 2-3 days if elevated), and ECG (repeated as needed). Also, check for Hep B virus serologies, Hep C virus antibody, and HIV antigen/antibody testing if these have not been previously performed. A portable CXR is done for most patients, and this is sufficient for the initial evaluation of pulmonary complications and the extent of lung involvement. Chest CT is usually reserved for circumstances that might change clinical management. Although specific characteristic chest CT findings may be seen in COVID-19, it cannot reliably distinguish COVID-19 from other causes of viral pneumonia. CTA is performed to rule out PE. Doppler US on BLE is done to rule out DVTs. An echocardiogram is ordered if there are increasing troponin levels with hemodynamic compromise or other cardiovascular findings suggestive of cardiomyopathy. Blood cultures and sputum GS and culture are ordered for suspicion of secondary bacterial infection. According to Mandell & Wunderink (2018), some tests can serve as markers of severe inflammation, and CRP and procalcitonin (PCT) are the most commonly used. Levels of these acute-phase reactants increase in the presence of an inflammatory response, specifically to bacterial pathogens. CRP may help identify worsening disease or treatment failure, and PCT may play a role in distinguishing bacterial from a viral infection, determining the need for antibacterial therapy, or deciding when to discontinue treatment. Community-acquired PNA (CAP) is a typical working diagnosis and is the differential diagnosis of patients presenting with respiratory tract infections with cough and abnormal chest imaging and patients with sepsis. Other respiratory tract infections that present similarly to CAP include, but are not limited to, influenza, acute bronchitis, chronic obstructive pulmonary disease exacerbations, and other respiratory tract infections.
Kim & Gandhi (2022) also wrote that empiric treatment for bacterial pneumonia might be appropriate in patients with suspected or documented COVID-19. Pharmacologic prophylaxis of VTE for all hospitalized patients with COVID-19 is advised, consistent with recommendations from several expert societies. The general strategy to address fever is acetaminophen as the preferred antipyretic agent. For patients with chronic conditions, continuing medications is recommended unless there are reasons to discontinue. Using immunosuppressing agents has been associated with increased risk for severe disease with other respiratory viruses, and the decision to continue or discontinue steroids, biologics, or other immunosuppressive drugs in COVID-19 must be determined on a case-by-case basis. Infection control (contact/respiratory isolation) is essential for managing patients with suspected or documented COVID-19. For patients who require mechanical ventilation or extracorporeal membrane oxygenation (ECMO), it is recommended to administer low-dose Dexamethasone within 24-48 hrs of ICU admission and within 96 hrs of hospitalization, and adjunctive Tocilizumab is suggested. Study data imply that dexamethasone and tocilizumab reduce mortality in this population when used early in hospitalization.
Some patients may develop ARDS and warrant intubation with mechanical ventilation. In addition to ARDS, other complications of infection include arrhythmias, acute cardiac injury, acute kidney injury, thromboembolic possibilities, severe sepsis, and shock (Kim & Gandhi, 2022). Liu et al. (2022) wrote that sepsis is a global threat because of high mortality. It is a significant risk factor for the development of long-lasting disabilities, including physical and cognitive impairment and mental disorders, known collectively as post-intensive care syndrome (PICS), which contributes to reduced health-related quality of life (HRQoL) for several years even after a successful recovery from the critically ill state. Sepsis survivors often need a more extended rehabilitation period, consume more medical and social resources, and struggle with financial burdens.
References
Kim, A.Y. & Gandhi, R.T. (January 24, 2022). Covid-19: Management in hospitalized adults. UpToDate. https://www.uptodate.com/contents/covid-19-management-in-hospitalized-adults?search=covid%20pneumonia&source
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Liu, K., Kotani, T., Nakamura, K., Chihiro, T. et al., (March 28, 2022). Effects of evidence-based ICU care on long-term outcomes of patients with sepsis or septic shock (ILOSS): protocol for a multicentre prospective observational cohort study in Japan. http://dx.doi.org/10.1136/bmjopen-2021-054478
Mandel, L.A. & Wunderink, R. (2018). Pneumonia. In Jameson, J.L., Kasper, D.L., Longo, D.L., Fauci, A.S., Hauser, S.L. & Loscalzo, J. (Eds). Harrison’s Principles of Internal Medicine (20th Ed, Vol.1, Part 1, Chap.121, pp.957-958). McGraw-Hill Education.
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