Case series study design was implemented. All cases were described in details. The data were collected retrospectively from the medical records. Confidentiality of participants was assured through the use of an anonymous research tool. Informed consents from surrogate decision makers were obtained, voluntary, by contacting them through their registered phone numbers. The collected data were used strictly for the purpose of the study objectives.
Case-1 Presentation
63 years old male was presented to the Emergency Isolation room at Imperial hospital on November the 26th complaining of cough, shortness of breath and fatigue. The symptoms started 2 weeks ago with dry cough only. The patient’s co-morbid conditions were hypertension and renal transplant 10 years ago with no other co-morbidity. Oxygen therapy was initiated through a non-rebreathing mask by a rate of 15 litre/minute, oxygen saturation was 97% with the mask. The patient was transferred for dialysis on day 2, the 28th of November. On day 4, the 29th of November, the patient started being anxious with oxygen drop to 88%, then immediately transferred to the isolation ICU. Table 1. below illustrates the medications received by the patient.
Chest computed tomography was done for the patient on the first day of hospital arrival, shown in figure 1. below.
On day 2 of the ICU, day 5 of hospital admission, the patient was on and off CPAP mask ventilation. Remdesivir was started on the 4th of December, day 5 of the ICU, with a loading dose of 200 mg in 250 mL normal saline intravenously followed by a maintenance dose of 100 mg in 250 mL normal saline daily, planned for 10 days. The patient was stable with mildly elevated serum creatinine, 1.7 mg/dl, and adequate urine output. The patient was seen by a nephrologist. On the 6th of December, the dose of enoxaparin was switched to the therapeutic dose, 80 mg B.D. On the 4th day of the remdesivir treatment, profound hypotension occurred and vasopressors were started. Despite the maximum dose of noradrenaline and dopamine along with normal saline, the hypotension persisted. Profound bradycardia occurred with a pulse rate of 36 bpm, and marked drop of oxygen saturation to 52% on CPAP mask. The patient was deceased 35 minutes later on the 7th of December, 2020.
Table 1: COVID-19 treatment medications administered to the patients
Medications
|
Medications
|
Remdesivir 200 mg I.V. LD, 100 mg I.V. O.D
|
Vitamin C 1000 mg daily
|
Meropenem 1 gm I.V B.D.
|
Zinc sulphate 15 mg daily
|
Enoxaparin 40mg S.C. B.D.
|
Azithromycin 500 mg daily
|
Dexamethasone 6 mg daily
|
Salbutamol nebulized solution 6 Hourly
|
Paracetamol 1gm I.V on need
|
Ipratropium nebulized solution 6 Hourly
|
Pantoprazole 40 mg I.V daily
|
Pulmicort 0.5 gm nebulized solution 6 Hourly
|
LD=Loading dose, I.V.= Intravenously, O.D.= Once daily, B.D.= Twice daily
Case-2 presentation
78 years old male was presented to the Emergency Isolation room at Imperial hospital on December the 8th with a positive PCR test for COVID-19. The swab was taken on the 4th of December, 2020 and the result was received on the 5th of December. SARS- COV-2 RNA by PCR was detected, while, SARS- COV-2 antibody was negative. The patient was complaining of shortness of breath for 3 days. His comorbidities were, diabetes mellitus (DM) on insulin treatment, and a history of Ca colon operated 2 years ago and he was on oral chemotherapy. The patient had no other co-morbid conditions. A confirmatory test by using RT-PCR was done on the 10th of December ( IgG 12.04, IgM 0.243). The medications in table 1. above, were given to the patient since day 1 and planned for 10 days, besides 1.5 litres of fluids. The patient was admitted to the isolation ICU on the same day of hospital arrival. Remdesivir was started on day 1, the 8th of December 2020. A loading dose of 200 mg was given in 250 mL of normal saline followed by a maintenance dose of 100 mg I.V in 250 mL of normal saline daily, planned for 10 days. On admission, the SPO2 was 92%, CPAP was applied. Table 2. below illustrated the daily vital signs of the patient.
Table 2: Daily vital signs of the patient ( Case-2)
Vital
signs
|
Day 1
8/12/2020
|
Day2
9/12l2020
|
Day 3
10/12/2020
|
Day 4
11/12/2020
|
Day 5
12/12/2020
|
Day 6
13/12/2020
|
SPO2
|
92%
|
94%
|
95%
|
94%
|
90%
|
83%, 80%
|
RR
|
30
|
35
|
33
|
30
|
32
|
34
|
HR
|
100
109 bpm
|
128
115 bmp
|
122
130 bpm
|
130 bpm
|
132 bpm
|
125 bpm
|
B.P.
|
130/70
140/80
|
139/87
133/85
|
149/92
168/100
|
170/83
|
155/83
|
99/56
Undetectable
84/40
|
GCS
|
15/15
|
15/15
|
13/15
|
10/15
|
10/15
|
3/15
|
RBG
|
233
402
|
343
230
|
300
370
|
350
310
|
369
368
|
268
280
|
Temp.
|
37.3
|
36.0
|
36.4
|
|
|
|
Laboratory examinations were done daily starting from day 3, the 10th of December. The results were presented in table 3 below.
Table 3: Results of laboratory examinations of the patient ( Case-2)
Laboratory tests
|
Day 3
|
Day 5
|
Laboratory tests
|
Day 3
|
Day 5
|
Blood Urea
|
121
|
|
pH
|
|
7.347
|
Serum creatinine
|
1.2 mg/dl
|
|
SO2%
|
|
97.50%
|
Na+ ( Sodium)
|
153 mmo/L
|
165.2 mmol/L
|
HCO3
|
|
27
|
K+ ( Potassium)
|
5.3 mmol/L
|
4.66 mmol/L
|
Hct
|
|
49.50%
|
D-dimer
|
5
|
|
Cl
|
|
114.5
|
CRP
|
215
|
|
Total protein
|
7.5 g/dL
|
7.6 g/dL
|
TWBCs
|
17.7
|
|
Serum albumin
|
2.4 g/dL
|
2.6 g/dL
|
RBCs
|
5.7
|
|
ALP
|
97 U/L
|
111 U/L
|
Neutrophis
|
88
|
|
ALT (GPT)
|
288 I.U/L
|
142 I.U/L
|
Lymphocytes
|
7
|
|
AST (GOT)
|
431 I.U/L
|
70 I.U/L
|
PLts
|
351
|
|
Prothrombin time
|
65 Sec.
|
24 Sec.
|
PCO2
|
|
50.6 mmHg
|
INR
|
>10
|
1.8
|
PO2
|
|
105.4 mmHg
|
APTT
|
49 Sec.
|
|
Chest computed tomography was done for the patient on the first day of hospital arrival, the 8th of December, shown in figure 2. below.
On day 2 in the ICU, the patient started doing better and getting stable. On day 3, the GCS was reducing and the patient started deteriorating. Nasogastric feeding was started and I.V fluids were increased to 3 litters per day alongside the same plan. On day 6, severe hypotension had occurred to the patient, to an extent that blood pressure was undetectable on any monitor or manual devices. Hypotension was resistant to fluids and vasopressors which eventually lead to the death of the patient. The patient was deceased on day 6, the 13th of December, as a result of severe refractory hypotension..
Case-3 presentation
75 years old male was presented to the Emergency Isolation room at Imperial hospital on the 18th of December 2020, with generalized fatigue and fever for 1 week, and hemiparesis. Co-morbid conditions of the patient were pacemaker device and BPH condition, which was operated 5 years ago. Oxygen saturation with CPAP mask was 87%. The patient was diagnosed with COVID-19 pneumonia and sepsis which were confirmed by PCR and CT-Chest. An incidence of haemorrhagic stroke was confirmed through brain imaging. The patient was admitted to the Isolation ICU immediately, with reduced GCS (9/15). Respiratory support was initiated with physiotherapy and prone positioning for 16 hours per day. 3 units of fresh frozen plasma (FFP), platelet concentrate 50 U/Kg and vitamin K 10 mg I.V. were administered. The patient developed hypernatremia (Serum Na+ 153), INR (2.8). Remdesivir was initiated on day 1 of admission, the 18th of December and stopped on day 5, the 23rd of December. Hypoalbuminemia was noticed on the 24th of December (2.2 g/dl), albumin 20% infusion was given twice daily for 4 days. On the 27th of December, the 10th day of hospital admission, the patient was transferred to a different healthcare facility. The medications in table 1, were given to the patient during the hospital stay.