Covid 19 Management

Dr. Sony Wibisono M dr. SpPD., KEMD., FINASIM

 Kondisi Covid19 dunia dan Indonesia
15 Juli 2020

https://www.worldometers.info/coronavirus/ https://covid19.go.id/peta-sebaran
 Penyakit penyerta :
Kondisi system imun yang rendah rentan Covid19
Incubation period
• The incubation period for COVID-19 is thought to extend to 14 days,
with a median time of 4-5 days from exposure to symptoms onset.
• One study reported that 97.5% of persons with COVID-19 who
develop symptoms will do so within 11.5 days of SARS-CoV-2
infection.3
Presentation
The signs and symptoms of COVID-19 present at illness onset vary, but
over the course of the disease, most persons with COVID-19 will
experience the following1,4-9:
• Fever (83–99%)
• Cough (59–82%)
• Fatigue (44–70%)
• Anorexia (40–84%)
• Shortness of breath (31–40%)
• Sputum production (28–33%)
• Myalgia (11–35%
Asymptomatic and Pre-Symptomatic Infection
• Several studies have documented SARS-CoV-2 infection in patients who never
develop symptoms (asymptomatic) and in patients not yet symptomatic (pre-
symptomatic).14,16,18-28 
• Since asymptomatic persons are not routinely tested, the prevalence of asymptomatic
infection and detection of pre-symptomatic infection is not well understood.
• One study found that as many as 13% of RT-PCR-confirmed cases of SARS-CoV-2 infection in
children were asymptomatic.14 
• Another study of skilled nursing facility residents infected with SARS-CoV-2 from a healthcare
worker demonstrated that HALF were asymptomatic or pre-symptomatic at the time of contact
tracing evaluation and testing.25 
• Patients may have abnormalities on chest imaging before the onset of
symptoms.19,20 
• Some data suggest that pre-symptomatic infection tended to be detected in younger
individuals and was less likely to be associated with viral pneumonia. 19,20
Asymptomatic and Pre-Symptomatic
Transmission
• Epidemiologic studies have documented SARS-CoV-2 transmission during the pre-
symptomatic incubation period19,29-31, and asymptomatic transmission has been
suggested in other reports.21,22,32 
• Virologic studies have also detected SARS-CoV-2 with RT-PCR low cycle thresholds, indicating larger
quantities of viral RNA, and cultured viable virus among persons with asymptomatic and pre-
symptomatic SARS-CoV-2 infection.23,25,28,33 
• The exact degree of SARS-CoV-2 viral RNA shedding that confers risk of transmission is not yet clear.
• Risk of transmission is thought to be greatest when patients are symptomatic since viral
shedding is greatest at the time of symptom onset and declines over the course of
several days to weeks.33-36 
• However, the proportion of SARS-CoV-2 transmission in the population due to
asymptomatic or pre-symptomatic infection compared to symptomatic infection is
unclear.37
Clinical Course
• Illness Severity. The largest cohort of > 44,000 persons with COVID-19
from China showed that illness severity can range from mild to
critical:38
• Mild to moderate (mild symptoms up to mild pneumonia): 81%
• Severe (dyspnea, hypoxia, or >50% lung involvement on imaging): 14%
• Critical (respiratory failure, shock, or multiorgan system dysfunction): 5%
Clinical Progression
• Among patients who developed severe disease, the medium time to dyspnea
ranged from 5 to 8 days, the median time to acute respiratory distress syndrome
(ARDS) ranged from 8 to 12 days, and the median time to ICU admission ranged
from 10 to 12 days.
• Clinicians should be aware of the potential for some patients to rapidly deteriorate
one week after illness onset.
• Among all hospitalized patients, a range of 26% to 32% of patients were admitted to the ICU.
• Among all patients, a range of 3% to 17% developed ARDS compared to a range of 20% to
42% for hospitalized patients and 67% to 85% for patients admitted to the ICU.
• Mortality among patients admitted to the ICU ranges from 39% to 72% depending
on the study.
• The median length of hospitalization among survivors was 10 to 13 days.
Risk Factors for Severe Illness
• Age is a strong risk factor for severe illness, complications, and death.
• Among more than 44,000 confirmed cases of COVID-19 in China, the case fatality
rate was highest among older persons:
• ≥80 years: 14.8%,
• 70–79 years: 8.0%,
• 60–69 years: 3.6%,
• 50–59 years: 1.3%,
• 40–49 years: 0.4%,
• <40 years: 0.2%.
• Early U.S. epidemiologic data suggests that the case fatality was highest in
persons aged ≥85 years (range 10%–27%), followed by 3%–11% for ages 65–84
years, 1%–3% for ages 55–64 years, and <1% for ages 0–54 years
 Epidemiology world – Indonesia (30 June 2020)

Age Age
0.4
5.7
1.3 13.3

3.6
>80 22.3 > 60
79-79 46-59
60-69 31-45
50-59 18-30
40-49 6sd17
14.8 26
< 40 0-5

30.4

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guida
nce-management-patients.html https://covid19.go.id/peta-sebaran
Reinfection
• There are no data concerning the possibility of re-infection with SARS-
CoV-2 after recovery from COVID-19.
• Viral RNA shedding declines with resolution of symptoms, and may
continue for days to weeks.
• However, the detection of RNA during convalescence does not
necessarily indicate the presence of viable infectious virus.
• Clinical recovery has been correlated with the detection of IgM and
IgG antibodies which signal the development of immunity
Viral Testing
• Diagnosis of COVID-19 requires detection of SARS-CoV-2 RNA by reverse transcription
polymerase chain reaction (RT-PCR).
• Detection of SARS-CoV-2 viral RNA is better in nasopharynx samples compared to throat
samples.
• Lower respiratory samples may have better yield than upper respiratory samples. SARS-
CoV-2 RNA has also been detected in stool and blood.
• Detection of SARS-CoV-2 RNA in blood may be a marker of severe illness.
• Viral RNA shedding may persist over longer periods among older persons and those
who had severe illness requiring hospitalization. (median range of viral shedding among
hospitalized patients 12–20 days).
• Infection with both SARS-CoV-2 and with other respiratory viruses has been reported,
and detection of another respiratory pathogen does not rule out COVID-19
Laboratory and Radiography
• Lymphopenia is the most common lab finding in
COVID-19 and is found in as many as 83% of
hospitalized patients.
• Lymphopenia, neutrophilia, elevated serum
alanine aminotransferase and aspartate
aminotransferase levels, elevated lactate
dehydrogenase, high CRP, and high ferritin levels
may be associated with greater  illness severity.1,
• Elevated D-dimer and lymphopenia have been
associated with mortality.
• Procalcitonin is typically normal on admission, but
may increase among those admitted to the ICU.
• Patients with critical illness had high plasma levels
of inflammatory makers, suggesting potential
immune dysregulation.5,
• Chest radiographs of patients with COVID-19
typically demonstrate bilateral air-space
consolidation,
• Chest CT images from patients with COVID-
19 typically demonstrate bilateral, peripheral
ground glass opacities.
• Because this chest CT imaging pattern is non-
specific and overlaps with other infections, the
diagnostic value of chest CT imaging for COVID-
19 may be low and dependent upon
radiographic interpretation.
• Given the variability in chest imaging
findings, chest radiograph or CT alone is not
recommended for the diagnosis of COVID-19.
Clinical Management and Treatment :
Mild to Moderate Disease
•• may
Older
notage
initially require hospitalization, and many patients will be able to
• manage
Chronictheir
kidney disease
illness at home.
•• The
COPD (chronic
decision obstructive
to monitor pulmonary
a patient disease)or outpatient setting
in the inpatient
• should be made on a case-by-case
Immunocompromised basis. immune system) from
state (weakened
solid
• This organ will
decision transplant
depend on the clinical presentation, requirement for
• supportive care, mass
Obesity (body potential risk[BMI]
index factors
offor
30severe disease, and the ability of
or higher)
• the patient
Serious to self-isolate
heart conditions,at home.
such as heart failure, coronary artery
• Patients
disease,with risk factors for severe illness (see 
or cardiomyopathies
• People Who Are at Higher Risk for Severe Illness) should be monitored
Sickle cell disease
closely given the possible risk of progression to severe illness in the second
• week
Type after
2 diabetes
symptom mellitus
onset.
Severe Disease
• Requiring hospitalization for management.
• Inpatient management revolves around the supportive management
of the most common complications of severe COVID-19:
• Pneumonia
• Hypoxemic respiratory failure/ARDS
• Sepsis and septic shock,
• Cardiomyopathy and arrhythmia
• Acute kidney injury
• Complications from prolonged hospitalization, including secondary bacterial
infections, thromboembolism, gastrointestinal bleeding, and critical illness
polyneuropathy/myopathy.
Hypercoagulability and COVID-19
• Some patients with COVID-19 may develop signs of a hypercoagulable state and be at increased risk for
venous and arterial thrombosis of large and small vessels.
• Laboratory abnormalities commonly observed among hospitalized patients with COVID-19-associated
coagulopathy include:
• Mild thrombocytopenia
• Increased D-dimer levels
• Increased fibrin degradation products
• Prolonged prothrombin time
• Elevated D-dimer levels have been strongly associated with greater risk of death. 70,72-75
• Thrombotic complications, most frequently deep venous thrombosis and pulmonary embolism. Other
reported manifestations include:
• Microvascular thrombosis of the toes
• Clotting of catheters
• Myocardial injury with ST-segment elevation
• Large vessel strokes
Investigational Therapeutics
Remdesivir (Last updated June 11, 2020)
• Recommendations for Hospitalized Patients with Severe COVID-19
• COVID-19 in hospitalized patients with SpO2 ≤94% on ambient air (at sea
level) or those who require supplemental oxygen (AI).
• patients who are on mechanical ventilation or extracorporeal membrane
oxygenation (ECMO) (BI)
• hospitalized patients with severe COVID-19 who are not intubated receive 5
days
• optimal duration of therapy for mechanically ventilated patients, patients on
ECMO, remdesivir treatment duration to up to 10 days (CIII)
Chloroquine or Hydroxychloroquine
(Last updated June 16, 2020)
• Recommends against the use of chloroquine or hydroxychloroquine for the
treatment of COVID-19, except in a clinical trial (AII).
• Recommends against the use of high-dose chloroquine (600 mg twice daily
for 10 days) for the treatment of COVID-19 (AI).
• serious dysrhythmias in patients , often in combination with azithromycin and
other medicines that prolong the QTc interval
• lower-dose chloroquine
• (450 mg twice daily for 1 day, followed by 450 mg once daily for 4 days)
• Hydroxychloroquine
• a twice-daily dose of hydroxychloroquine 600 mg on the first day and 400 mg daily for
4 additional days
Lopinavir
(Last updated May 12, 2020) oral dosing
• Against the use of lopinavir/ritonavir (AI) or other HIV protease
inhibitors (AIII) for the treatment of COVID-19, except in the context
of a clinical trial
• Lopinavir 400 mg/ritonavir 100 mg orally twice daily for 14 days
• Adverse Effects Include:
• Nausea
• vomiting,
• diarrhea (common)
• QTc prolongation
• Hepatotoxicity
 Discontinuation of Transmission-Based
Precautions or Home Isolation
• Patients who have clinically recovered and are able to discharge from
the hospital but who have not been cleared from their Transmission-
Based Precautions may continue isolation at their place of residence
until cleared.
• The decision to discontinue Transmission-Based Precautions for
patients with confirmed COVID-19  should be made using either a
test-based strategy or a symptom-based (i.e., time-since-illness-onset
and time-since-recovery strategy) or time-based strategy)
Symptomatic patients with COVID-19 should remain in
Transmission-Based Precautions until either:
• Symptom-based strategy
• At least 3 days (72 hours) have passed since recovery defined as resolution of
fever without the use of fever-reducing medications and improvement in
respiratory symptoms (e.g., cough, shortness of breath); and,
• At least 10 days have passed since symptoms first appeared
• Test-based strategy
• Resolution of fever without the use of fever-reducing medications and
• Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
• Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay
for detection of SARS-CoV-2 RNA from at least two consecutive respiratory
specimens collected ≥24 hours apart (total of two negative specimens) [1].
Patients with laboratory-confirmed COVID-19 who have not had any
symptoms 
should remain in Transmission-Based Precautions until either:

• Time-based strategy
• 10 days have passed since the date of their first positive COVID-19 diagnostic test,
assuming they have not subsequently developed symptoms since their positive test.
Note, because symptoms cannot be used to gauge where these individuals are in the
course of their illness, it is possible that the duration of viral shedding could be longer
or shorter than 10 days after their first positive test.
• Test-based strategy
• Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for
detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens
collected ≥24 hours apart (total of two negative specimens). Note, because of the
absence of symptoms, it is not possible to gauge where these individuals are in the
course of their illness. There have been reports of prolonged detection of RNA without
direct correlation to viral culture.
Discontinuation of empiric Transmission-Based
Precautions for patients suspected of having COVID-19
• by excluding the diagnosis of COVID-19 for a suspected COVID-19
patient can be made based upon having negative results from at least
one FDA Emergency Use Authorized COVID-19 molecular assay for
detection of SARS-CoV-2 RNA
• If a higher level of clinical suspicion for COVID-19 exists, consider a
second test for SARS-CoV-2 RNA.
• If a patient suspected of having COVID-19 is never tested, can be
made based upon using the symptom-based strategy 
Disposition of Patients with COVID-19:

• Patients can be discharged from the healthcare facility whenever

clinically indicated.
• If discharged to home:
• Isolation should be maintained at home if the patient returns home before
discontinuation of Transmission-Based Precautions. The decision to send the
patient home should be made in consultation with the patient’s clinical care
team and local or state public health departments. It should include
considerations of the home’s suitability for and patient’s ability to adhere to
home isolation recommendations.
Disposition of Patients with COVID-19:
• Patients can be discharged from the healthcare facility whenever clinically
indicated
• If discharged to a nursing home or other long-term care facility (e.g., assisted living
facility), AND
• Transmission-Based Precautions are still required, they should go to a facility with an ability to
adhere to infection prevention and control recommendations for the care of COVID-19 patients.
Preferably, the patient would be placed in a location designated to care for COVID-19 residents.
• Transmission-Based Precautions have been discontinued, but the patient has persistent
symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be
restricted to their room to the extent possible, and wear a facemask (if tolerated) during care
activities until all symptoms are completely resolved or at baseline.
• Transmission-Based Precautions have been discontinued and the patient’s symptoms have
resolved, they do not require further restrictions, based upon their history of COVID-19.
https://doi.org/10.1016/S2213-8587(20)30152-2
Consideration of potential metabolically interfering effects of drugs
in suspected or COVID-19 positive patients with type 2 diabetes

• Metformin
• Dehydration and lactic acidosis will probably occur if patients are dehydrated, so patients
should stop taking the drug and follow sick day rules
• During illness, renal function should be carefully monitored because of the high risk of
chronic kidney disease or acute kidney injury
• Sodium-glucose-co-transporter 2 inhibitors
• These include canagliflozin, dapagliflozin, and empagliflozin
• Risk of dehydration and diabetic ketoacidosis during illness, so patients should stop taking
the drugs and follow sick day rules
• Patients should avoid initiating therapy during respiratory illness
• Renal function should be carefully monitored for acute kidney injury

https://doi.org/10.1016/S2213-8587(20)30152-2
Consideration of potential metabolically interfering effects of drugs
in suspected or COVID-19 positive patients with type 2 diabetes

• Glucagon-like peptide-1 receptor agonists

• These include albiglutide, dulaglutide, exenatide-extended release, liraglutide, lixisenatide, and semaglutide
• Dehydration is likely to lead to a serious illness so patients should be closely monitored
• Adequate fluid intake and regular meals should be encouraged
• Dipeptidyl peptidase-4 inhibitors
• These include alogliptin, linagliptin, saxagliptin, and sitagliptin
• These drugs are generally well tolerated and can be continued
• Insulin
• Insulin therapy should not be stopped
• Regular self-monitoring of blood-glucose every 2–4 hours should be encouraged, or continuous glucose
monitoring
• Carefully adjust regular therapy if appropriate to reach therapeutic goals according to diabetes type,
comorbidities, and health status

https://doi.org/10.1016/S2213-8587(20)30152-2
PEDOMAN PENDERITA DIABETES SAAT
SAKIT.
1. TETAP TERHIDRASI
2. UKUR GLUKOSA DARAH ANDA
3. UKUR SUHU ANDA
4. JIKA ANDA MENGGUNAKAN INSULIN, UKUR JUGA KETON DARAH
ANDA
5. PATUHI REKOMENDASI TIM KESEHATAN ANDA
 MAKAN MAKANAN YANG BERVARIASI DAN
SEIMBANG
(menjaga Gula Stabil dan meningkatkan Sistem Kekebalan Tubuh)
• Utamakan makanan dengan indeks glikemik rendah (mis. Sayuran,
pasta gandum /mie)
• Hindari konsumsi makanan gorengan yang berlebihan
• Batasi konsumsi makanan gula tinggi, karbohidrat, dan lemak
• Pilih protein tanpa lemak (mis. Ikan, daging, telur, susu, kacang
setelah matang penuh).
• Makanlah sayuran hijau dan berdaun
• Makan buah dalam dua atau tiga porsi
Terimakasih