Posted on 04/25/2020 4:43:48 PM PDT by Devils_Tower
This is a must read for the best all round treatment.
Make sure to read page 9 and 11 for comments on how WHO led the world in the wrong direction
Summary https://www.evms.edu/media/evms_public/departments/internal_medicine/Marik-Covid-Protocol-Summary.pdf
evms.edu/covidcare
btt
Info on CV19
Bkmk
Ping
Virginia one of the States that won’t let them use hydroxy unless the patient is virtually dead?
It is interesting that the clinicians, who are actually treating patients, are converging on similar protocols.
Dr. Zelenko, Dr. Raoult in France, and now this.
Some potentially effective, and cheap therapies getting massive resistance from the MSM, Democrat pols, and some docs. Why?
To continue to embarrass the President?
Protocol: HCQ + ZPAK + Zn.
Thanks for posting. They left out one possible treatment that could be fit into their regimen.
GOOD READ: https://arxiv.org/abs/2003.12444
Hat tip to President Trump.
What I found interesting is that this group thinks the recommended standard care has led to the deaths of tens of thousands of patients. They reject intubation if at all possible and they state that recommendations by the WHO and CDC to avoid corticosteroids are errors. And they think the disease process has been misunderstood which has led to unsuccessful treatments.
One thing is for sure...it would be hard to argue in favor of intubation. Use of ventilators is almost a death sentence with this disease.
On a more positive note the authors indicated that they are having great success with the protocol they outline here. Things could certainly change if doctors are able to treat covid-19 successfully.
I was originally read the prevent treatment by my Dr. on a Tele heath app in March. I did not know for certain where it came from. I do now and when I saw the 20 Apr version, I decided to put in front of as many people as possible.
If you note, the ventilator and icu shortage has started to ease. My hope is that this treatment is more wide spread than discussed.
absalom01 wrote:
“It is interesting that the clinicians, who are actually treating patients, are converging on similar protocols.
Dr. Zelenko, Dr. Raoult in France, and now this.
Some potentially effective, and cheap therapies getting massive resistance from the MSM, Democrat pols, and some docs. Why?”
One word.
Money.
There’s more money in experimental drugs n vaccines.
Can you post the latest info from Dr Raoult?
I can’t find his latest study.
HCQ is most often used for the treatment and prevention of malaria. Malaria and Covid-19 both attack the hemoglobin of the blood. In each case, HCQ protects the hemoglobin from being destroyed.
For example, disruption of the hemoglobin by cyanide or carbon monoxide causes hypoxia because hemoglobin is what carries oxygen throughout our body. The hypoxia of Covid-19 is not only because the lung function is damaged, but the virus also attacks the hemoglobin which carries the body's oxygen. HCQ protects the hemoglobin.
Nicotine seems to have some positive effects also but I don’t expect the AMA to admit it.
Mom MD, do you have an opinion on the treatment presented in this paper?
https://arxiv.org/pdf/2003.12444.pdf
If the above link directly to the pdf does not work, the pdf can be accessed at the below linked abstract:
https://arxiv.org/abs/2003.12444
Note: This is an 11 page protocol with commentary.
Page 1 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 | evms.edu/covidcareEVMS CRITICAL CARECOVID-19 MANAGEMENT PROTOCOL
Developed and updated by Paul Marik, MDChief of Pulmonary and Critical Care MedicineEastern Virginia Medical School, Norfolk, VAApril 20th,
2020URGENT! Please circulate as widely as possible. It is crucial that every pulmonologist, every critical care doctor and nurse, every hospital administrator, every public health official receive this information immediately.This is our recommended approach to COVID-19 based on the best (and most recent) literature. We should not re-invent the wheel but learn from the experience of others.
This is a very dynamic situation; therefore, we will be updating the guideline as new information emerges. Please check on the EVMS website for updated versions of this protocol.
EVMS COVID website: https://www.evms.edu/covid-19/medical_information_resources/Short url: evms.edu/covidcare
“If what you are doing ain’t working, change what you are doing”Dr AB (NYC).
“We have zero success for patients who were intubated. Our thinking is changing to postpone intubation to as long as possible, to prevent mechanical injury from the ventilator. These patients tolerate arterial hypoxia surprisingly well. Natural course seems to be the best.”
Page 2 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 | evms.edu/covidcareFigure
1. The course of COVID-19 and General Approach to treatment
Page 3 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 | evms.edu/covidcareProphylaxisWhile there is very limited data (and none specific for COVID-19), the following “cocktail” may have a role in the prevention/mitigation of COVID-19 disease.
While there is no high level evidence that this cocktail is effective; it is cheap, safe and widely available.
•Vitamin C 500 mg BID and? Quercetin 250-500 mg BID •Zinc 75-100 mg/day (acetate, gluconate or picolinate). Zinc lozenges are preferred. After 1-2 months, reduce the dose to 30-50 mg/day. •Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 1-2 mg at night •Vitamin D3 1000-4000 u/day (optimal dose unknown). Mildly Symptomatic patients (at home): •Vitamin C 500 mg BID and? Quercetin 250-500 mg BID (if available) •Zinc 75-100 mg/day•Melatonin 6-12 mg at night (the optimal dose is unknown) •Vitamin D3 1000-4000 u/day •Optional: ASA 81 -325 mg/day •Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days
Mildly Symptomatic patients (on floor): •Vitamin C 500mg BID and Quercetin 250-500 mg BID (if available) •Zinc 75-100 mg/day•Melatonin 6-12 mg at night (the optimal dose is unknown) •Vitamin D3 1000-4000 u/day •Enoxaparin 40-60 mg daily •Optional: Methylprednisolone 40 mg daily •Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days •Optional: Remdesivir, only available in clinical trials •N/C 2L /min if required (max 4 L/min; consider early t/f to ICU for escalation of care). •Avoid Nebulization and Respiratory treatments. Use “Spinhaler” or MDI and spacer if required. •Avoid non-invasive ventilation •T/f EARLY to the ICU for increasing respiratory signs/symptoms.
Page 4 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 | evms.edu/covidcareRespiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: admit to ICU):
Essential Treatment (dampening the STORM)
1.Methylprednisolone 80 mg loading dose then 40mg q 12 hourly for at least 7 days and until transferred out of ICU.
Alterative approach: Hydrocortisone 50 mg q 6 hourly.
2.Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until transferred out of ICU. Note caution with POC glucose testing (see below).
3.Full anticoagulation: Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c q 12 hourly (dose adjust with Cr Cl < 30mls/min). Heparin is suggested with CrCl < 15 ml/min.
Alternative approach: Half-dose rTPA: 25mg of tPA over 2 hours followed by a 25mg tPA infusion administered over the subsequent 22 hours, with a dose not to exceed 0.9 mg/kg followed by full anticoagulation.
Note: Early termination of ascorbic acid and corticosteroids will likely result in a rebound effect (see Figure 2).
Additional Treatment Components (the Full Monty
4.Melatonin 6-12 mg at night (the optimal dose is unknown).
5.Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent hypomagnesemia (which increases the cytokine storm and prolongs Qtc).
6.Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days (has immunomodulating properties including downregulating IL-6; in addition Rx of concomitant bacterial pneumonia).
7.Optional: Atorvastatin 40-80 mg/day. Of theoretical but unproven benefit. Statins have been demonstrated to reduce mortality in the hyper-inflammatory ARDS phenotype. Statins have pleotropic anti-inflammatory, immunomodulatory, antibacterial and antiviral effects. In addition, statins decrease expression of PAI-1
8.Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected based on procalcitonin levels and resp. culture (no bronchoscopy).Co-infection with other viruses appears to be uncommon, however a full respiratory viral panel is still recommended. Superadded bacterial infection is reported to be uncommon (however, this may not be correct).
9.Maintain EUVOLEMIA (this is not non-cardiogenic pulmonary edema). Due to the prolonged “symptomatic phase” with flu-like symptoms (6-8 days) patients may be volume depleted. Cautious rehydration with 500 ml boluses of Lactate Ringers may be warranted, ideally guided by non-invasive hemodynamic monitoring. Diuretics should be avoided unless the patient has obvious intravascular volume overload.
10.Early norepinephrine for hypotension. While the angiotenin II agonist Giapreza ™ has a limited role in septic shock, this drug may uniquely be beneficial in patients with COVID-19 (downregulates ACE-2).
Page 5 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 | evms.edu/covidcare11.Escalation of respiratory support (steps);
Try to avoid intubation if at all possible, (see Figure 3) •Accept “permissive hypoxemia” (keep O2 Saturation > 84%) •N/C 1-6 L/min•High Flow Nasal canula (HFNC) up to 60-80 L/min•Trial of inhaled Flolan (epoprostenol)•Attempt proning (cooperative repositioning-proning; see Figure) •Intubation ... by Expert intubator; Rapid sequence. No Bagging; Full PPE. Crash/emergency intubations should be avoided. •Volume protective ventilation; Lowest driving pressure and lowest PEEP as possible. Keep driving pressures < 15 cmH2O. •Moderate sedation to prevent self-extubation•Trial of inhaled Flolan (epoprostenol)•Prone positioning•?? ECMO < 60 yrs. and no severe commodities/organ failure. There is widespread concern that using HFNC could increase the risk of viral transmission. There is however, no evidence to support this fear. HFNC is a better option for the patient and the health care system than intubation and mechanical ventilation. CPAP/BiPAP may be used in select patients, notably those with COPD exacerbation or heart failure.A sub-group of patients with COVID-19 deteriorates very rapidly. Intubation and mechanical ventilation may be required in these patients."
I read that because the hemoglobin can’t carry the oxygen to where it’s needed, that ventilators were almost useless and when they turn them up, it was damaging the lungs from the pressure.
Here is the Raoult abstract:
https://www.medrxiv.org/content/10.1101/2020.03.16.20037135v1.full.pdf+html
Here is the daily record for the therapy:
https://www.mediterranee-infection.com/covid-19/
To date: 3081 treated — 13 deaths
I would expect this to spread like wildflowers among doctors. They are desperate to start “flattening the (death) curve.”
Page 5 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 |
evms.edu/covidcare
11.Escalation of respiratory support (steps); Try to avoid intubation if at all possible, (see Figure 3)
•Accept “permissive hypoxemia” (keep O2 Saturation > 84%) •N/C 1-6 L/min•High Flow Nasal canula (HFNC) up to 60-80 L/min
•Trial of inhaled Flolan (epoprostenol)•Attempt proning (cooperative repositioning-proning; see Figure)
•Intubation ... by Expert intubator; Rapid sequence. No Bagging; Full PPE. Crash/emergency intubations should be avoided.
•Volume protective ventilation; Lowest driving pressure and lowest PEEP as possible. Keep driving pressures < 15 cmH2O. •Moderate sedation to prevent self-extubation
•Trial of inhaled Flolan (epoprostenol)•Prone positioning•?? ECMO < 60 yrs. and no severe commodities/organ failure.
There is widespread concern that using HFNC could increase the risk of viral transmission. There is however, no evidence to support this fear.
HFNC is a better option for the patient and the health care system than intubation and mechanical ventilation.
CPAP/BiPAP may be used in select patients, notably those with COPD exacerbation or heart failure.
A sub-group of patients with COVID-19 deteriorates very rapidly. Intubation and mechanical ventilation may be required in these patients.
12. Treatment of secondary HLH (increasing Ferritin, CRP and transaminases)
•“High dose corticosteroids.” Methylprednisolone 120 mg q 8 hourly for at least 3 days, then wean accruing to CRP, IL-6, Ferritin etc (see Figure 4).
•Tocilizumab (IL-6 inhibitor) as per dosing guideline. •Consider plasma exchange 13.Monitoring•Daily: PCT, CRP, IL-6, BNP, Troponins, Ferritin, Neutrophil-Lymphocyte ratio, D-dimer and Mg.
CRP, IL-6 and Ferritin track disease severity closely.
Thromboelastogram (TEG) on admission and repeated as indicated.
•In patients receiving IV vitamin C, the Accu-Chek™ POC glucose monitor will result in spuriously high blood glucose values. Therefore, a laboratory glucose is recommended to confirm the blood glucose levels.
•Monitor QTc interval if using chloroquine/hydrochloroquine and azithromycin and monitor Mg++ (torsades is uncommon in monitored ICU patients)
•No routine CT scans, follow CXR and chest ultrasound.
•Follow ECHO closely; Pts develop a severe cardiomyopathy.
Page 6 of 11 | EVMS Critical Care COVID-19 Management Protocol 04-20-2020 | evms.edu/covidcare
14.Post ICU managementa.Enoxaparin 40-60 mg s/c dailyb.
Methylprednisone 40 mg day, the wean slowlyc.
Vitamin C 500 mg PO BIDd.
Melatonin 3-6 mg at nig
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