The COVID-19 Textbook


SECTION 5 • Medical Response

There have been several reports of young adults, typically less than 50 years old, who present with significant troponin and natriuretic peptide elevation, nonspecific ECG findings, and left ven tricular systolic dysfunction. Such patients appear to be similar to children with MIS-C, typically having high inflammatory biomarkers such as C-reactive protein and IL-6, often with gastrointesti nal symptoms and less commonly severe pulmonary involvement. 24 Treatment of this multisystem inflammatory syndrome in adults (MIS-A) is poorly defined, but largely modeled on the treatment for MIS-C including the use of intravenous immunoglobulin and/or glucocorticoids. Treatment is guided by acute cardiomyopathy guidelines and has included mechanical circulatory support. Left ventricular systolic function typically recovers quickly (on the order of days) similar to other causes of fulminant myocarditis. Management of Acute Kidney Failure Hospitalized patients with COVID-19 may present with or develop acute kidney failure. Patients not requiring renal replacement therapy are managed with supportive measures and avoidance of nephrotoxic agents. Judicious use of intravenous fluids is important to avoid pulmonary edema in patients on supplemental oxygen. Indications for renal replacement therapy are similar to those in patients without COVID-19. Patients with COVID-19 are at increased risk of circuit thrombosis. 25 Unless contraindicated, circuit In the absence of documented or strongly suspected thromboembolism, anticoagulation dosing and strategy is largely determined by the severity of illness. The degree of anticoagulation may be further tailored based on the individual’s risk for hypercoagulability and bleeding. Heparin is the preferred agent but for patients with contraindications to heparin, fondaparinux may be used instead. Patients who are hospitalized and are not hypoxemic should receive prophylactic anticoagulation unless otherwise contraindicated. 4 Patients admitted to a non–intensive care unit (ICU) setting with low-flow supplemental oxy gen therapy and d-dimer levels above the upper limit of normal should receive therapeutic antico agulation with heparin; if patients are pregnant or comorbidities are present in which therapeutic anticoagulation would be contraindicated, then prophylactic doses of heparin are recommended instead. 4,26,27 Unless the patient has another indication for therapeutic anticoagulation, such as known or suspected thromboembolic disease, patients with critical illness who are admitted to the ICU requir ing oxygen by high-flow nasal canula, noninvasive mechanical ventilation, or invasive mechanical ventilation should be treated with heparin prophylaxis. 4,28,29 The risk of life-threatening hemorrhage in critically patients on therapeutic anticoagulation alters the risk/benefit calculus for this group. Postacute Sequelae of SARS-CoV-2 Infection or Long COVID-19 Important complications of COVID-19 include PASC or long COVID-19. Patients with PASC have recovered from acute COVID-19 but have new or persisting symptoms and signs for weeks, months, or years after the acute disease and for which there is no trigger or explanation other than COVID-19. The cause of PASC is currently unknown. There have been multiple proposed mech anisms, including persistence of SARS-CoV-2 infection, induction of autoantibodies, excessive in flammation, autonomic dysfunction, and many other potential causes. It is possible that multiple etiologies will ultimately be proven to be involved. Typically reported symptoms and signs include fatigue, the feeling of “brain fog,” inattention or difficulty focusing, dyspnea, tachycardia in response to standing or minimal exertion, and chest discomfort. Further studies are needed to characterize the causes of PASC and to evaluate therapies. Current leads for therapeutic research include evaluation of antiviral or immunosuppressive medications during acute COVID-19 as well as during the period with long COVID-19. No strong recommendations can be made for the treatment of PASC at this time given the current evidence base. or systemic anticoagulation is recommended. Thromboembolism Prophylaxis

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