Update Tatalaksana Covid-19

Dr. Muhammad Alkaff, SpPD

Agustus 2020
Disclaimer
• Data ttg Covid-19 berkembang dari waktu ke waktu.
• Diambil dari berbagai sumber yang sahih yang resmi dan juga pendapat para ahli.
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
Overview

“COVID-19 IS A SYSTEMIC DISEASE”

(Prof DR. dr. Ari Fahrial Syam, SpPD, KGEH, MMB. Dekan FKUI, Mei 2020)

Temgoua MN,et al. 13 July 2020. doi.org/10.1007/s42399-020-00417-7

• Belum ada terapi definitif……

Thousand Faces Disease

Diarrhea
Kidney failure
©Prof Iris Rengganis
 6 Agustus 2020

https://covid19.who.int/
 6 Agustus 2020

https://covid19.who.int/
 ASEAN, 6 Agustus 2020

https://covid19.who.int/
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
16 Mar 2020 April 2020

23 Mar 2020

13 Juli 2020

• Begitu cepat update…….

• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
 Port d’entree
• Virological analysis of 9 cases of COVID-19 that provides proof
of active virus replication in tissues of the upper respiratory
tract.
• Pharyngeal virus shedding was very high during the first week
of symptoms, with a peak at 7.11 × 108 RNA copies per throat
swab on day 4
• Seroconversion occurred after 7 days in 50% of patients (and
by day 14 in all patients), but was not followed by a rapid
decline in viral load.

Wolfel R, et al. Virological assessment of hospitalized patients with COVID-2019 https://doi.org/10.1038/s41586-020-2196-x

 Swab nasoorofaring paling banyak (+) saat hari
ke-4 s/d 18,
Terhitung dari awal simptom (demam)

PCR SARSCoV2 paling sensitif pada sediaan

swab (naso-orofaring) dan sputum

Wolfel R, et al. Virological assessment of hospitalized patients with COVID-2019 https://doi.org/10.1038/s41586-020-2196-x

 Rapid serologi mulai menjadi (+) pada hari ke>4
Pada hari >8, walaupun PCR swab terdeteksi (+), tapi tidak
tumbuh virus pada media kultur → dianggap tidak infeksius??
Wolfel R, et al. DOI:10.1038/s41586-020-2196-x
 • A surrogate marker of ‘viral load’ with PCR is the cycle
threshold value (Ct).
• A low Ct value indicates a high viral RNA amount, and vice
versa.
• As noted above, detection of viral RNA does not necessarily
mean the presence of infectious or viable virus.
• The median period of incubation is estimated to be ~5 • In a local study from a multicenter cohort of 73 COVID-19
days (range 2-14 days) patients, when the Ct value was 30 or higher (i.e. when
• Infected persons might remain asymptomatic and viral load is low), no viable virus (based on being able to
estimates of asymptomatic infection have been wide, culture the virus) has been found.
ranging from 17.9% - 78%. • In addition, virus could not be isolated or cultured after
• Study estimated that the infectious period of SARS-CoV-2 day 11 of illness. These active viral replication drops quickly
started 2.3 days before onset of symptoms, peaking at after the first week, and viable virus was not found after the
0.7 days, and declining within 7 days. second week of illness despite the persistence of PCR
• By day 15 from onset of illness, 30% of all COVID-19 detection of RNA.
patients are PCR-negative by nasopharyngeal swab, this Ct Value: …..25 30 35 40….
rises to 68% by day 21 and 88% by day 28 and by day 33,
95% of all patients are negative by PCR. PCR positif, dan PCR msh positif, tapi PCR negatif
infeksius tdk infeksius
 • We report temporal patterns of viral shedding in 94
patients with laboratory-confirmed COVID-19 and
modeled COVID-19 infectiousness profiles from a
separate sample of 77 infector–infectee transmission
pairs.

MASA INKUBASI
MASA INFEKSIUS

ASIMPTOMATIK
INFEKSIUS
SPEKTRUM KLINIS

Gangg organ lainnya dan perburukan penyakit penyerta

• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
Penggunaan CQ/HCQ
di Indonesia
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19 (Data, Patofis, Algoritme)
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
 Bukti Gangg Koagulasi pada Covid-19

1. Hiperkoagulasi
2. Thrombosis events
– Arterial: ACS, acute CVD stroke
– Venous : DVT, PE
J Thromb Haemost. 2020;18:844–847. J Thromb Haemost.2020;18:1094–1099
 31% incidence of thrombotic complications in ICU patients
Jangan menunggu terjadi
THROMBOTIC EVENTS… with COVID-19 infections is remarkably high and well
→ profilaksis omparable to the VTE incidence in other patient
categories with overt DIC.

Our findings reinforce the recommendation to strictly

apply pharmacological thrombosis prophylaxis in all
COVID-19 patients admitted to the ICU, and are
suggestive of increasing the prophylaxis towards high-
prophylactic doses
• Klok FA, et al. Thrombosis Research 191 (2020) 145-7.
 Profil Hemostasis Pasien Covid-19
RSUP Persahabatan (Juni 2020)
Karakteristik N=48 Karakteristik N=48
Pria 23 (47,9%) NLR (Neutrofil to Lymphocyte ratio)
wanita 25 (52,1%) <3 12 (25%)
Usia 17-83 tahun 3-5 11 (22,9%)
In hospital mortality 8 (16,7%) >5 25 (52,1%)
Rapid serologi 17 (35,4%) Profil hemostasis
Anemia (Hb<10 g/dl) 15 (31,2%) D-dimer normal (<500) 8 (16,7%)
Komorbid D-dimer 500-1000 9 (18,8%)
Hipertensi 12 (25%) D-dimer >1000 31 (64,6%)
DM 7 (14,6%)
PT <1,3x kontrol 45 (98,3%)
CAD/CHF 5 (10,4%)
PT 1,3-1,5x kontrol 2 (4,2%)
Hep B/C 6 (12,5%)
PT <1,3x kontrol 1(2,1%)
Asma/PPOK 5 (10,4%)
APTT <1,3x kontrol 32 (66,7%)
Komplikasi yang terjadi
APTT 1,3-1,5x kontrol 11 (22,9%)
Sepsis 21 (43,8%) APTT <1,3x control 5 (10,4%)
Kardiovaskular (ACS) 17 (35,4%)
Gangguan ginjal 14 (29,2)
Gangguan hati 15 (31,2%)

• Paramita D, Alkaff M, et al. 2020 [unpublished]

 Patogenesis Gangg Koagulasi pada Covid-19
❑ Patients with COVID-19 are at increased risk of venous thromboembolism
(VTE), which is a deep vein thrombosis (DVT) or pulmonary embolism (PE)
❑ COVID-19 may predispose to both venous and arterial thromboembolic
disease due to excessive inflammation, hypoxia, immobilization and
diffuse intravascular coagulation (DIC) (Klok et al., 2020)
❑ It is still unknown if this is higher risk than other critically ill patients.
❑ An elevated D-dimer is commonly seen in patients with COVID-19 (40-
50%)
❑ Pulmonary embolism should be considered in admitted patients with
COVID-19 who have a sudden onset of oxygenation deterioration,
respiratory distress of hypotension
c
KOMORBIDITAS Mortalitas
>>

Badai Sitokin
 • JACC. VOL. 7 5 , NO . 2 3 , 2 0 2 0

Patofis: Cytokine Strom

D-dimer & prolonged PT sebagai prediktor mortalitas

 Derajat sedang

→Perlu RANAP
→ perlu profilaksis

OTG /asimptomatik
dan derajat ringan

→ rajal, isolasi mandiri

• JACC. VOL. 75, NO . 23, 2020

DOI: 10.1111/jth.14929
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
 Manajemen Komorbid dan Komplikasi
Pria
Karakteristik N=48
23 (47,9%)
• Identifikasi awal adanya komorbid
wanita
Usia
25 (52,1%)
17-83 tahun
(anamnesis + PF)
In hospital mortality 8 (16,7%)
Rapid serologi
Anemia (Hb<10 g/dl)
17 (35,4%)
15 (31,2%)
• Skrining awal rutin:
Komorbid
Hipertensi 12 (25%)
– Cek GD
– Cek Cr
DM 7 (14,6%)
CAD/CHF 5 (10,4%)
Hep B/C 6 (12,5%)
Asma/PPOK
Komplikasi yang terjadi
5 (10,4%) – Cek SGPT
Sepsis
Kardiovaskular (ACS)
21 (43,8%)
17 (35,4%)
– Anti HIV → ARV
Gangguan ginjal 14 (29,2)
Gangguan hati 15 (31,2%) – EKG
– Status nutrisi: BB, TB
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit

•Via droplet saluran napas (batuk/bersin)
•Kontak dekat <2m (salaman, cipika-cipiki)
Memegang permukaan/benda yang
bervirus (gagang pintu/tombol
lift/meja/dll), lalu menyentuh
mulut/hidung/mata tanpa cuci tangan

•Aerosol-generating
procedures
•Tindakan medis aerosol
•Berbicara diruang sempit
tertutup

•Kontaminasi Feses (?)

 Updates Modes of transmission
a. Contact and droplet transmission
b. Airborne transmission:
• Disseminated droplet nuclei (<5um)
• Aerosol generating prosedures (3-16
hours)
• Indoor crowded setting with poor
ventilation
c. Fomite transmission:
• Contaminated surfaces (plastics, metals)
d. Other modes of transmission :
• urine, feces
• intrauterine transmission (uncertain)
• bloodbourne (?)

Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. WHO Scientific brief
Memegang permukaan/benda yang
bervirus (gagang pintu/tombol
lift/meja/dll), lalu menyentuh
mulut/hidung/mata tanpa cuci tangan
 Transmisi di dalam ruangan
Surfaces Bentuk desain ruangan ?
• Ventilasi ruang sempit
• Durasi
• Jarak tatap muka dlm
ruang tertutup
• Overview
• Panduan Kemenkes Ed.5
• Kinetika Virus
• Penggunaan CQ/HCQ
• Gangguan Koagulasi pada Covid-19
• Manajemen Komorbid Lain
• Mode Transmisi
• Pencegahan Penularan Intra dan Ekstra Rumah Sakit
 Pencegahan di komunitas (ekstra Fasyankes)
1. Physical distancing: di fasilitas umum, kendaraan umum, dll
2. Cuci tangan
3. Pakai masker, face shield
 Pencegahan Penularan di Fasyankes
1. Transmisi dari pasien ke pasien lain:
• Atur jarak antar bed
• Atur ventilasi ruang rawat/poli/ruang tunggu
• Semua pasien selalu bermasker
1. Aktifkan Tim PPI
• Pengaturaan sirkulasi udara AC dan exhaust fan. RS/Libatkan diri dg
2. Transmisi dari pasien ke dirinya sendiri/autotransmisi: PPI
• Persering ganti sprei
• Kurangi tirai 2. Terlibat aktif dlm
• Persering disinfeksi permukaan (pel lantai, lap meja
pasien, handle pintu. edukasi
3. Transmisi dari pasien ke Nakes: pasien/keluarga,
• Pakai APD sesuai level ruangan
upaya promosi
4. Transmisi Nakes ke Nakes:
• Tidak nongkrong/makan bersama di doctor lounge
kesehatan
• Proses pelepasan APD
 Take home message
• COVID 19 adl penyakit sistemik, jalan masuk sal napas.
• Update selalu perkembangan terbaru
• Cegah penularan/klaster RS
• Kenali karakteristik komorbid pasien
• Kolaborasi dan kerjasama tim adalah keharusan