While anti-viral drug Remdesivir is recommended for mild to severe Covid-19 cases under expert advice, the cost of the injection and even its results still being under scrutiny are a major factor that most Punjab hospitals are avoiding its use.
Dr Rajesh Bhaskar, nodal officer for Covid-19 management in Punjab, said, ‘’No government hospital in Punjab has used Remdesivir, though it has also become part of treatment as of now. In private hospitals as well, its use is very limited.”
This is also evident from treatment manual released by the Punjab government which has been printed in three colours Green (Level 1 patients), Yellow (Level 2 patients) and Red (Level 3 patients).
According to the manual, mild or Level 1 patients that are asymptomatic can be treated at home by home isolation as well, for which they need to isolate themselves from other family members of the house, record oxygen levels of the body twice a day using pulse oximeters. They should also have Vitamin C and Zinc as supplements.
However, in case of high risk asymptomatic patients (with any lifestyle disease), Hydroxychloroquine (HCQ) course is completed for 5 days under medical supervision. Paracetamol is given to patients in case they develop fever in Level 1 category itself.
Dr Bishav Mohan, cardiologist at the DMCH and also part of team of doctors that developing this treatment manual for Covid patients in Punjab, said, “If Level 1 patients in home isolation are facing difficulty in breathing, have pain in chest, mental confusion, bluish lips/face or decreased urine output, they must contact their doctor without any delay as they need to be hospitalised at this stage while Level 1 patients in hospitals are taken care of by the medical officers on duty.”
For Level 2 patient, Dr Mohan explains, “The above mentioned symptoms result in involvement of lungs, pneumonia-like symptoms also develop with no sign of severe disease. In this case, the patient must be admitted to the district Covid-19 health centre (DCHC). ECG monitoring is a must for this patient. Again HCQ dose for 5 days is given to moderate patients (Level 2). Antibiotic dose is also required and apart from this depending upon the requirement of the patient, dosage of Dexamethasone (steroid ) is given intravenously. No doubt oxygen level monitoring is needed on a regular basis and even blood thinners are given to patients under medical supervision so as to avoid clots as patients develop these during hospitalisation.” Meanwhile it needs to be mentioned that Azithromycin is the popular antibiotic being used in covid treatment.
He added,”Instead of Dexamethasone, Remdesivir has been used in one or two hospitals of Punjab. However, so far this drug has its limited use in Punjab. Dexamethasone injection costs in the range of Rs 10-20 a dose, while Remdesivir is in thousands. Cost is a major factor. Also, Remdesivir can be used if two experts recommend. So far, for active patients in Punjab Dexamethasone is working well.”
Plasma Therapy also comes as part of Level 2 patients’ treatment which again has been done in limited numbers only.
The manual says that if respiratory distress increases, the patient needs to be shifted to Level 3 category (severe) where invasive or non-invasive ventilators are being used for patients depending upon the severity of the case. Non-invasive involves face masks for oxygen supply for less severe patients, while invasive ventilators involve tracheal intubation. Anti-virals continue along with this treatment.” Apart from this, Toclizumab injection which is usually used for rheumatoid arthritis patients is being used as an anti-inflammatory medication in Level 3 patients to counter Cytokine storm (severe inflammation) which occurs in some Covid-19 patients. Injection Methylprednisolone can also be given if Dexamethasone is not given to the patient,” added Dr Mohan.
One unique therapy which Punjab hospitals are offering is ‘prone positioning’ to increase oxygen saturation in the body so that patients do not need to go on ventilators. Dr Mohan said, “Results of patients on ventilators are not encouraging at all and hence, we try our level best to treat them without use of ventilators. Prone positioning is making patients lie on their bellies so as to improve oxygen levels in patients. We are following it on Level 2 as well as Level 3 patients so as to make all attempts to avoid sending them on ventilators. No doubt advanced oxygen supply is also given to the patients. “
Meanwhile, Punjab government data revealed that out of 221 deaths nearly 50 per cent of them happened on ventilators.
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