Update Tatalaksana Covid-19

Dr. Muhammad Alkaff, SpPDAgustus 2020

Disclaimer

• Data ttg Covid-19 berkembang dari waktu ke waktu.

• Diambil dari berbagai sumber yang sahih yang resmi dan juga pendapat para ahli.

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

Overview

“COVID-19 IS A SYSTEMIC DISEASE”(Prof DR. dr. Ari Fahrial Syam, SpPD, KGEH, MMB. Dekan FKUI, Mei 2020)

• Belum ada terapi definitif……

Temgoua MN,et al. 13 July 2020. doi.org/10.1007/s42399-020-00417-7

Thousand Faces Disease

©Prof Iris Rengganis

Diarrhea

Kidney failure

6 Agustus 2020

https://covid19.who.int/

6 Agustus 2020

https://covid19.who.int/

ASEAN, 6 Agustus 2020

https://covid19.who.int/

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

23 Mar 2020

13 Juli 2020

16 Mar 2020 April 2020

• Begitu cepat update…….

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

Port d’entree

• Virological analysis of 9 cases of COVID-19 that provides proof of active virus replication in tissues of the upper respiratory tract.

• Pharyngeal virus shedding was very high during the first week of symptoms, with a peak at 7.11 × 108 RNA copies per throat swab on day 4

• Seroconversion occurred after 7 days in 50% of patients (and by day 14 in all patients), but was not followed by a rapid decline in viral load.

Wolfel R, et al. Virological assessment of hospitalized patients with COVID-2019 https://doi.org/10.1038/s41586-020-2196-x

Swab nasoorofaring paling banyak (+) saat harike-4 s/d 18,

Terhitung dari awal simptom (demam)

PCR SARSCoV2 paling sensitif pada sediaanswab (naso-orofaring) dan sputum

Wolfel R, et al. Virological assessment of hospitalized patients with COVID-2019 https://doi.org/10.1038/s41586-020-2196-x

Rapid serologi mulai menjadi (+) pada hari ke>4

Wolfel R, et al. DOI:10.1038/s41586-020-2196-x

Pada hari >8, walaupun PCR swab terdeteksi (+), tapi tidaktumbuh virus pada media kultur→ dianggap tidak infeksius??

• The median period of incubation is estimated to be ~5 days (range 2-14 days)

• Infected persons might remain asymptomatic and estimates of asymptomatic infection have been wide, ranging from 17.9% - 78%.

• Study estimated that the infectious period of SARS-CoV-2 started 2.3 days before onset of symptoms, peaking at 0.7 days, and declining within 7 days.

• By day 15 from onset of illness, 30% of all COVID-19 patients are PCR-negative by nasopharyngeal swab, this rises to 68% by day 21 and 88% by day 28 and by day 33, 95% of all patients are negative by PCR.

• A surrogate marker of ‘viral load’ with PCR is the cycle threshold value (Ct).

• A low Ct value indicates a high viral RNA amount, and vice versa.

• As noted above, detection of viral RNA does not necessarily mean the presence of infectious or viable virus.

• In a local study from a multicenter cohort of 73 COVID-19 patients, when the Ct value was 30 or higher (i.e. when viral load is low), no viable virus (based on being able to culture the virus) has been found.

• In addition, virus could not be isolated or cultured after day 11 of illness. These active viral replication drops quickly after the first week, and viable virus was not found after the second week of illness despite the persistence of PCR detection of RNA.

PCR negatifPCR positif, daninfeksius

Ct Value: …..25 30 35 40….

PCR msh positif, tapitdk infeksius

• We report temporal patterns of viral shedding in 94 patients with laboratory-confirmed COVID-19 and modeled COVID-19 infectiousness profiles from a separate sample of 77 infector–infectee transmission pairs.

MASA INFEKSIUS

MA

SA IN

KU

BA

SI

ASIMPTOMATIK INFEKSIUS

SPEKTRUM KLINIS

Gangg organ lainnya dan perburukan penyakit penyerta

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

Penggunaan CQ/HCQ di Indonesia

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19 (Data, Patofis, Algoritme)

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

Bukti Gangg Koagulasi pada Covid-19

1. Hiperkoagulasi

2. Thrombosis events– Arterial: ACS, acute CVD stroke

– Venous : DVT, PE

J Thromb Haemost. 2020;18:844–847. J Thromb Haemost.2020;18:1094–1099

31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high and well

omparable to the VTE incidence in other patient categories with overt DIC.

Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all

COVID-19 patients admitted to the ICU, and are suggestive of increasing the prophylaxis towards high-

prophylactic doses

• Klok FA, et al. Thrombosis Research 191 (2020) 145-7.

Jangan menunggu terjadiTHROMBOTIC EVENTS…

→ profilaksis

Profil Hemostasis Pasien Covid-19 RSUP Persahabatan (Juni 2020)

Karakteristik N=48Priawanita

23 (47,9%)25 (52,1%)

Usia 17-83 tahunIn hospital mortality 8 (16,7%)Rapid serologi 17 (35,4%)Anemia (Hb

Patogenesis Gangg Koagulasi pada Covid-19

❑Patients with COVID-19 are at increased risk of venous thromboembolism(VTE), which is a deep vein thrombosis (DVT) or pulmonary embolism (PE)

❑COVID-19 may predispose to both venous and arterial thromboembolicdisease due to excessive inflammation, hypoxia, immobilization anddiffuse intravascular coagulation (DIC) (Klok et al., 2020)

❑ It is still unknown if this is higher risk than other critically ill patients.

❑An elevated D-dimer is commonly seen in patients with COVID-19 (40-50%)

❑Pulmonary embolism should be considered in admitted patients withCOVID-19 who have a sudden onset of oxygenation deterioration,respiratory distress of hypotension

c

KOMORBIDITAS

Badai Sitokin

Mortalitas>>

• JACC. VOL. 7 5 , NO . 2 3 , 2 0 2 0

D-dimer & prolonged PT sebagai prediktor mortalitas

Patofis: Cytokine Strom

• JACC. VOL. 75, NO . 23, 2020

Derajat sedang

→Perlu RANAP→ perlu profilaksis

OTG /asimptomatikdan derajat ringan

→ rajal, isolasi mandiri

DOI: 10.1111/jth.14929

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

Manajemen Komorbid dan Komplikasi• Identifikasi awal adanya komorbid

(anamnesis + PF)

• Skrining awal rutin:

– Cek GD

– Cek Cr

– Cek SGPT

– Anti HIV → ARV

– EKG

– Status nutrisi: BB, TB

Karakteristik N=48Priawanita

23 (47,9%)25 (52,1%)

Usia 17-83 tahunIn hospital mortality 8 (16,7%)Rapid serologi 17 (35,4%)Anemia (Hb

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

•Via droplet saluran napas (batuk/bersin)•Kontak dekat

Updates Modes of transmission

Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. WHO Scientific brief

a. Contact and droplet transmission

b. Airborne transmission:

• Disseminated droplet nuclei (

Memegang permukaan/benda yang bervirus (gagang pintu/tombollift/meja/dll), lalu menyentuhmulut/hidung/mata tanpa cuci tangan

Transmisi di dalam ruangan

• Ventilasi ruang sempit

• Durasi

• Jarak tatap muka dlmruang tertutup

Surfaces Bentuk desain ruangan ?

• Overview

• Panduan Kemenkes Ed.5

• Kinetika Virus

• Penggunaan CQ/HCQ

• Gangguan Koagulasi pada Covid-19

• Manajemen Komorbid Lain

• Mode Transmisi

• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

Pencegahan di komunitas (ekstra Fasyankes)

1. Physical distancing: di fasilitas umum, kendaraan umum, dll

2. Cuci tangan

3. Pakai masker, face shield

Pencegahan Penularan di Fasyankes

1. Aktifkan Tim PPI RS/Libatkan diri dg PPI

2. Terlibat aktif dlmedukasipasien/keluarga, upaya promosikesehatan

1. Transmisi dari pasien ke pasien lain:• Atur jarak antar bed • Atur ventilasi ruang rawat/poli/ruang tunggu• Semua pasien selalu bermasker• Pengaturaan sirkulasi udara AC dan exhaust fan.

2. Transmisi dari pasien ke dirinya sendiri/autotransmisi:• Persering ganti sprei• Kurangi tirai• Persering disinfeksi permukaan (pel lantai, lap meja

pasien, handle pintu.

3. Transmisi dari pasien ke Nakes:• Pakai APD sesuai level ruangan

4. Transmisi Nakes ke Nakes:• Tidak nongkrong/makan bersama di doctor lounge• Proses pelepasan APD

Take home message

• COVID 19 adl penyakit sistemik, jalan masuk sal napas.

• Update selalu perkembangan terbaru

• Cegah penularan/klaster RS

• Kenali karakteristik komorbid pasien

• Kolaborasi dan kerjasama tim adalah keharusan