Co-Morbidity Based Questions
|
Frequently Asked Inpatient Questions Microchapter |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ogechukwu Hannah Nnabude, MD Rinky Agnes Botleroo, M.B.B.S.
Co-Morbidity Based Questions
Patients with Hypertension
Should ACE Inhibitors and ARBs be discontinued in patients on admission for COVID-19?
- Based on current studies, it is advisable to continue the current treatment of chronic disease conditions including hypertension with either ACEI or ARB during the COVID-19 pandemic,
Patients with Asthma
Should an Asthma exacerbation be managed any differently to reduce the risk of COVID-19?
The selection of therapeutic options through the guideline-recommended treatment of asthma exacerbation has not been affected by what we currently know about COVID-19. Systemic corticosteroids should be used to treat an asthma exacerbation per national asthma guidelines and current standards of care, even if it is caused by COVID-19. Short-term use of systemic corticosteroids to treat asthma exacerbation should be continued. There is currently no evidence to suggest that short-term use of systemic corticosteroids to treat asthma exacerbation increases the risk of developing severe COVID-19, whereas there is an abundance of data to support use of systemic steroids for moderate or severe asthma exacerbation. Patients with asthma but without symptoms or a diagnosis of COVID-19 should continue any required nebulizer for treatments, as recommended by national professional organizations. If healthcare providers need to be present during nebulizer use among patients who have either symptoms or a diagnosis of COVID-19, they should use recommended precautions when performing aerosol-generating procedures (AGPs). If clinicians are concerned that an asthma exacerbation is related to an underlying infection with COVID-19, clinicians can access laboratory testing for COVID-19 through a network of state and local public health laboratories across the country.
Are any changes recommended to the treatment plan of an asthma patient with COVID 19?
If patients with asthma who have symptoms or a diagnosis of COVID-19 need to use nebulizer at home, it is recommended by national professional organizations that they should use the nebulizer in a location that minimizes and preferably avoids exposure to any other members of the household, and preferably a location where the air is not recirculated into the home (like a porch, patio, or garage). Limiting the number of people in the room or location where the nebulizer is used is also recommended. Nebulizers should be used and cleaned according to the manufacturer’s instructions. If nebulizer use in a healthcare setting is necessary for patients who have either symptoms or a diagnosis of COVID-19, they must use recommended precautions when performing aerosol-generating procedures (AGPs).
Patients currently Undergoing Hemo-dialysis
Can patients continue receiving Hemo-dialysis in a hospital where other COVID-19 patients are treated?
Do patients with suspected or confirmed COVID-19 need to wear masks during their dialysis treatment?
- Patients receiving dialysis in their own room or an isolation room do not need to wear a mask if dialysis staff are working from outside the room. If dialysis staff are remaining in the room with the patient, the patient should wear a facemask if tolerated. Dialysis staff in the room should use all recommended PPE(Personal Protective Equipment).When patients with confirmed COVID-19 are being dialyzed in the acute dialysis unit, the patient should wear a facemask for the duration of treatment. Dialysis staff in the room should adhere to appropriate Transmission-Based Precautions and use all recommended PPE.
Where should intermittent hemodialysis be performed in the acute care setting?
For patients with suspected or confirmed COVID-19 requiring intermittent hemodialysis in the acute care setting, dialysis should ideally be performed in the patient’s hospital room with the door closed. This serves to limit the patient’s movement within the hospital.
If the patient is to be dialyzed in the acute care dialysis unit, consider the following:
- Transporting patient to the acute care dialysis unit:
When a patient with suspected or confirmed COVID-19 is being transported to the acute care dialysis unit, ensure HCP(Health Care Personnel) adhere to recommended infection control practices like using personal protective equipment. The patient should wear a facemask during transportation.
- Dialyzing patient in an acute care dialysis unit isolation room:
If the acute care dialysis unit has an isolation room, hemodialysis should be performed in the isolation room with the door closed. Hepatitis B isolation rooms should only be used for dialysis patients with confirmed or suspected COVID-19 if:
- The patient is hepatitis B surface antigen positive or
- The facility has no patients on the census with hepatitis B infection who would require treatment in the isolation room.
The isolation room should be terminally cleaned after the care of each patient with COVID-19.
- Dialyzing several patients with confirmed COVID-19 (cohorting) in a shared room in the acute care dialysis unit:
In a situation where there are several patients with confirmed COVID-19 requiring hemodialysis (non-ICU), consider cohorting the patients on the same dialysis shift, preferably the last dialysis shift of the day to allow for terminal cleaning of the dialysis unit following treatment. If possible, patients without COVID-19 should not receive dialysis during the same shift (in the same room); if patients without COVID-19 are dialyzed at the same time in the unit, they should be kept at least 6 feet away from the COVID-19 patients at all times. Patients with confirmed or suspected COVID-19 should continue to wear their facemask during treatment and adhere to appropriate respiratory hygiene and cough etiquette.
Cancer Patients
Can/Should Cancer surgery be delayed? What about radiation therapy?
Malignant melanoma is more aggressive. The best curative treatment is the early complete surgical removal. In case of metastatic disease, systemic treatment has become increasingly effective with a significant prolongation of survival for responders. In patients with metastatic melanoma, treatment delay may result in a loss of the window to treat. For solid tumor patients, “adjuvant therapy with curative intent likely should proceed” according to Ueda et al.
Should immune-suppressive treatments be discontinued or delayed?
Systemic corticosteroids are not recommended in acute COVID‐19, since doses ≥20 mg/ d are immunosuppressive and may prolong the viral shedding.
Among the biologicals, the theoretical risk of COVID‐19 infection seems to be higher with inhibitors of tumor necrosis factor alpha (TNF‐α) compared to interleukin (IL) inhibitors. Among the TNF‐α, the risk seems to be somewhat increased with infliximab and its biosimilars. In general, TNF‐α is not recommended during infectious disease.
Ustekinumab, risankizumab, ixekizumab, and brodalumab do not increase the risk of respiratory infections in general. However, the data should be interpreted with caution, since we do not have the data for COVID‐19 yet.
There are reports on drug‐induced interstitial lung disease by infliximab, adalimumab, and ustekinumab.32 Patients with pre-existent pulmonary problems have a higher risk for COVID‐19.
Are support groups or activities still available in the hospital?
Should patients take an antiviral medication such as Tami flu for protection?
Oseltamivir(branded as Tamiflu) is a drug approved for treatment of influenza A and B. Oseltamivir targets the neuraminidase distributed on the surface of the influenza virus to inhibit the spread of the influenza virus in the human body. A study in Wuhan reported that no positive outcomes were observed after receiving antiviral treatment with oseltamivir . Several clinical trials are still evaluating the effectiveness of oseltamivir in treating SARS-CoV-2 infection. Oseltamivir is also used in clinical trials in several combinations, such as with chloroquine and favipiravir.