What do I think, as a doctor, of the Health circular on Covid treatment at home
The post of the doctor Stefano Biasioli. Subject: the circular from the Ministry of Health on Covid treatment at home
Subject: the circular from the Ministry of Health on Covid treatment at home
These are 16 pages, many of which are questionable, for an old hospital doctor (such as I am) who has always been used to dealing with nephrological-dialysis emergencies and acute endocrinological pathologies.
Let's summarize and then comment on this “classic Italian circular”.
SUMMARY
A score will define the state of the Covid patient managed at home by the family doctor: based on some parameters, which would allow patients to be divided into three risk categories.
A points scale – called Mews (modified early warning score) – we reiterate, to define the status of the Covid patient who should be at the family doctor, probably without a home visit but only with telephone or IT support (and consequent aspect medico-legal).
The novelty is foreseen in the circular of the Ministry of Health, published yesterday, for the "home management of patients with SarsCov2 infection", which provides doctors and pediatricians with guidelines for the care of these patients at home: from drugs to be used in '' indication of the situations in which a direct visit by the doctor is recommended.
The recommendations refer to the pharmacological management in the home setting of mild cases of Covid-19 and apply to both confirmed and probable cases.
The Mews scale will serve to quantify the severity of the clinical picture of the Covid patient at home and its evolution. Clinical instability is correlated in the scale to the alteration of physiological parameters (blood pressure, heart rate, respiratory rate, temperature, level of consciousness, oxygen saturation) and would allow to identify the risk of rapid clinical deterioration or death. Using the Mews scale, patients are then stratified into 3 risk groups: low / stable (score 0-2); medium / unstable (score 3-4); high / critical (score 5).
The evaluation of the parameters "at the time of diagnosis of infection and daily monitoring, also through telephone approach, especially in mild symptomatic patients would be fundamental since" – reads the circular – "about 10-15% of mild cases progress to severe forms ".
How do you manage the patient at home, according to Speranza and C.?
a) periodic measurement of oxygen saturation (which must not be below 92%) using oximeters;
b) symptomatic treatments (paracetamol), appropriate hydration and nutrition e
c) the warning not to modify existing chronic therapies for other pathologies, as this would risk causing aggravation of pre-existing conditions.
Commentino (interlocutory): few certainties and news, so far. The family doctor as an "observer away from the scene".
The circular continues:
Compared to the drugs to refer to, it is recommended not to use corticosteroids routinely (recommended only in severe subjects who need oxygen supplementation); do not use heparin (use is only indicated in subjects immobilized due to the infection in progress); do not use antibiotics (their possible use is to be reserved only in the presence of persistent febrile symptoms for over 72 hours or whenever the clinical picture raises the well-founded suspicion of bacterial overlap). It is also indicated not to use hydroxychloroquine, “whose efficacy has not been confirmed in any of the clinical studies conducted so far”. It is also recommended not to administer drugs by aerosol if in isolation with other cohabitants due to the risk of spreading the virus in the environment.
The circular then underlines that "to date, there is no solid evidence of the efficacy of vitamin supplements and food supplements (for example vitamins, including vitamin D, lactoferrin, quercetin), the use of which for this indication is therefore not recommended".
To manage the patient, it is emphasized, the collaboration with the special Usca Continuity Care Units that provide home care is fundamental.
Another comment (interlocutory): how many are there today, in the individual Italian regions, the Usca?
The circular continues: "in situations of aggravation of the patient it is highly recommended that, in the presence of an adequate supply of personal protective equipment, doctors and paediatricians, also integrated in the Usca, can guarantee a direct assessment of the patient through the execution of home visits ".
Another comment (interlocutory): highly recommended … provided that …
COMMENTS FROM FIMMG AND FNOMCEO
Discounted and unrealistic… .us usual. Indeed:
1) Positive comment from the secretary of the Federation of general practitioners (Fimmg) Silvestro Scotti: "Finally, doctors have univocal indications and a single point of reference, but it is a document to be kept under surveillance and continuously updated if – he concludes – there was new scientific evidence ".
2) For the president of the National Federation of Medical Orders (Fnomeo), Filippo Anelli, “the crucial role of the general practitioner and the free choice pediatrician has been recognized”.
Another comment (interlocutory): and the patient, where do we put him?
FINAL COMMENT
We absolutely do not share the document. Because it is a blame game and takes away any hope of being properly treated at home.
The gist: Watching and paracetamol for fever.
Do nothing, indeed be careful not to use the drugs that the practice of the last 10 months has shown to be effective, in the world …
FnomCeo and FIMMG can "bless" the circular as long as they want. Once again they show that they are neither on the side of the doctor-treating nor on the side of the patient.
We do not think so and we are on the side of the many who think like Remuzzi, like all Mario Negri, Suter etc, who advise to treat immediately (3 days after the appearance of the first symptoms, often even before the swab, given the technicians to carry it out) with azithromycin / plaquenil / cortisone (dexamethasone or other) / low molecular weight heparin.
These are the drugs that I "put at home" and that I would use, in case of need. I made 14 swabs 14, all negative. But you never know: “leap year, fatal year”.
For me, the circular – in absolute terms – has no value: clinical, deontological, moral. And I think and think about friends, who ended up badly because they were treated late, with approaches similar to those in the circular.
Stefano Biasioli
Nb) But, at the Ministry, does anyone read world literature, in these terrible months? Have you ever read the Medscape articles on Covid-19?
THE DOCUMENT OF HOPE & C. IN DETAIL
Definition of a low-risk patient. "Low-risk patients are defined by the absence of increased risk factors (eg neoplastic diseases or immunosuppression) and on the basis of the following characteristics:
• flu-like symptoms (eg rhinitis, cough without breathing difficulties, myalgia, headache);
• absence of dyspnea and tachypnea (documenting whenever possible the presence of an SpO2> 92%);
• fever £ 38 ° C or> 38 ° C for less than 72 hours;
• gastro-enteric symptoms (in the absence of dehydration and / or multiple diarrheal discharges);
• asthenia, ageusia / dysgeusia / anosmia. "
The oximeter. "The monitoring of clinical conditions and oxygen saturation will be continued in the subject infected with SARS-CoV-2 for the entire duration of home isolation – the circular states -, in relation to the clinical conditions and territorial organization . The patient must be instructed on the need to communicate a change in the parameters with respect to the baseline and, in particular, must communicate oxygen saturation values below 92%. If the need for hospitalization is excluded, the supply of home oxygen therapy may be activated, with all the prudential assessments of the feasibility of the case ".
The indications. In particular, in asymptomatic or paucisymptomatic subjects at home, on the basis of the information and data currently available, the following indications for clinical management are provided:
• watchful waiting;
• periodic measurement of oxygen saturation by pulse oximetry;
• symptomatic treatments (for example paracetamol);
• appropriate hydration and nutrition;
• do not modify existing chronic therapies for other pathologies (eg antihypertensive, lipid-lowering, anticoagulant or antiplatelet therapies), as this would risk causing aggravation of pre-existing conditions;
• subjects in chronic immunosuppressive treatment due to a previous solid organ transplant rather than for diseases with immune-mediated pathogenesis, will be able to continue the pharmacological treatment in progress unless otherwise indicated by the treating specialist; • do not use corticosteroids routinely;
• the use of corticosteroids is recommended in subjects with severe COVID-19 disease who need oxygen supplementation. The use of these drugs at home can only be considered in those patients whose clinical picture does not improve within 72 hours, in the presence of a worsening of pulse oximetry parameters that require oxygen therapy;
• do not use heparin. The use of this drug is indicated only in subjects immobilized due to the infection in progress;
• do not use antibiotics. Their possible use is to be reserved only in the presence of persistent febrile symptoms for over 72 hours or whenever the clinical picture raises the well-founded suspicion of bacterial overlap, or, finally, when the bacterial infection is demonstrated by a microbiological examination. ;
• do not use hydroxychloroquine whose efficacy has not been confirmed in any of the controlled clinical studies conducted so far;
• do not administer drugs by aerosol if in isolation with other cohabitants due to the risk of spreading the virus in the environment
This is a machine translation from Italian language of a post published on Start Magazine at the URL https://www.startmag.it/sanita/cosa-penso-da-medico-della-circolare-della-salute-sul-trattamento-covid-a-domicilio/ on Fri, 04 Dec 2020 08:52:40 +0000.