If you want a practical succinct plan to protect you and your family from COVID-19, implement the protocol that has been working best by Dr. Paul Marik, Chief of Critical Care and Pulmonary Medicine at E. Virginia Medical School.
This matches the program also recommended by Dr. Shiva Ayyadurai. His recomendation to President Trump is here as https://shiva4senate.com/immune-and-economic-health-for-america-coronavirus/.
After you have printed Dr. Marik's Protocol, go back and click the link above to see the recommended Vitamin regimen by Dr. Shiva. The link says shiva4senate, but don't worry, this link is for a copy of the letter to President Trump for how to protect the American People.
Please use these vitamins to prepare your immune system to defeat SARS-CoV-2 when you come into contact with it.. Don’t wait until you go to the hospital, since many doctors having 80 to 88% fatality rates in hospitals where they are putting patients on ventilators. The doctors having almost no deaths were not using ventilators but using Intravenous Vitamin C Therapy. The answer to the COVID-19 crisis is immune health. For a detailed explanation later, please read my other blog post in a 5 part series.
For now, I will print out the exact text from Dr. Paul Marik who has asked that this be provided to every family, government official, doctor, and medical facility in the U.S.
He has 3 parts. 1. Prophylaxis - what you need now. 2. Mildly Symptomatic or in Hospital not in ICU, and 3. Critical Condition in ICU.
The important takeaway is this: If you get seriously ill, do not allow yourself to be blindly put on a ventilator, tell your doctor you want to INSIST on Dr. Marik’s Recommended Protocol shown and on the link.
PRINT THIS LINK AND PROVIDE TO YOUR ADMITTING PHYSICIAN
https://www.evms.edu/media/evms_public/departments/internal_medicine/Marik-Covid-Protocol-Summary.pdf
EVERY WORD BELOW THIS LINE IS COPIED FROM THE LINK- THE EXACT WORDS OF DR. MARIK
Prophylaxis
While there is very limited data (and none specific for COVID-19), the following “cocktail” may have a role in the prevention/mitigation of COVID-19 disease, especially amongst the most vulnerable citizens in our community; i.e. those over the age of 60 years and those with medical comorbidities. While there is no high level evidence that this cocktail is effective; it is cheap, safe and should be readily available. So what is there to lose?
• Vitamin C 500 mg BID
• Zinc 75-100 mg/day (acetate, gluconate or picolinate; do not use for more than 2 months)
• Quercetin 500-1000 mg/day
• Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 1-2 mg at night
• Vitamin D3 1000-4000 iu/day (optimal dose unknown; likely that those with baseline low 25-OH
vitamin D and those > 40o latitude will benefit the most)
Mildly Symptomatic patients (at home):
■ Vitamin C 500mg BID
■ Quercetin 250-500 mg BID (if available)
■ Zinc 75-100 mg/day
■ Melatonin 6-12 mg at night (the optimal dose is unknown)
■ Vitamin D3 1000-4000 iu/day
■ Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days
Hospitalized with Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: admit
to ICU):Additional Treatment Components (the Full Monty)
Essential Treatment (dampening the STORM)
1. Methylprednisolone 80 mg loading dose then 40mg q 12 hourly for at least 7 days and until transferred out of ICU. Alterative approach: Hydrocortisone 50 mg q 6 hourly.
2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until transferred out of ICU. Note caution with POC glucose testing (see below).
General schema for respiratory support in patients with COVID-19
TRY TO AVOID INTUBATION IF POSSIBLE
Low-Flow Nasal Cannula
■ Typically set at 1-6 Liters/Min
High Flow Nasal Cannula (Limitation on Flow Rate)
■ Accept permissive hypoxemia (O2 Saturation > 86%)
■ Titrate FiO2 based on patient’s saturation
■ Accept flow rates of 60 to 80 L/min
■ Trial of inhaled Flolan (epoprostenol)
■ Attempt proning (cooperative proning)
Invasive Mechanical Ventilation
■ Target tidal volumes of ~6 cc/kg
■ Lowest driving pressure and PEEP
■ Sedation to avoid self-extubation
■ Trial of inhaled Flolan
Prone Positioning
■ Exact indication for prone ventilation is unclear
■ Consider in patients with PaO2/FiO2 ration < 150
VV-ECMO
■ Indications remain unclear
■ Early discussion with ECMO center or team may be advisable
3. Full anticoagulation: Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c q 12 hourly (dose adjust with
Cr Cl < 30mls/min). Heparin is suggested with CrCl < 15 ml/min. Alternative approach: Half-dose rTPA: 25mg of tPA over 2 hours followed by a 25mg tPA infusion administered over the subsequent 22 hours, with a dose not to exceed 0.9 mg/kg followed by full anticoagulation. On transfer to floor, consider reducing enoxaparin to 40-60 mg /day. Note: Early termination of ascorbic acid and corticosteroids will likely result in a rebound effect.
4. Melatonin 6-12 mg at night (the optimal dose is unknown).
5. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent hypomagnesemia (which increases the cytokine storm and prolongs Qtc).
6. Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days (has immunomodulating properties including downregulating IL-6; in addition Rx of concomitant bacterial pneumonia).
7. Optional: Atorvastatin 40-80 mg/day. Of theoretical but unproven benefit. Statins have been demonstrated to reduce mortality in the hyper-inflammatory ARDS phenotype. Statins have pleotropic anti-inflammatory, immunomodulatory, antibacterial and antiviral effects. In addition, statins decrease expression of PAI-1
8. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected based on procalcitonin levels and resp. culture (no bronchoscopy).
Co-infection with other viruses appears to be uncommon, however a full respiratory viral panel is still recommended. Superadded bacterial infection is reported to be uncommon (however, this may not be correct).
9. Maintain EUVOLEMIA (this is not non-cardiogenic pulmonary edema). Due to the prolonged “symptomatic phase” with flu-like symptoms (6-8 days) patients may be volume depleted. Cautious rehydration with 500 ml boluses of Lactate Ringers may be warranted, ideally guided by non-invasive hemodynamic monitoring. Diuretics should be avoided unless the patient has obvious intravascular volume overload.
10. Early norepinephrine for hypotension. While the angiotenin II agonist GiaprezaTM has a limited role in septic shock, this drug may uniquely be beneficial in patients with COVID-19 (downregulates ACE-2).
11. Escalation of respiratory support (steps); Try to avoid intubation if at all possible
■ Accept “permissive hypoxemia” (keep O2 Saturation > 84%)
■ N/C 1-6 L/min
■ High Flow Nasal canula (HFNC) up to 60-80 L/min
■ Trial of inhaled Flolan (epoprostenol)
■ Attempt proning (cooperative repositioning-proning; see Figure)
■ Intubation... by Expert intubator; Rapid sequence. No Bagging; Full PPE. Crash/emergency intubations should be avoided.
Volume protective ventilation; Lowest driving pressure and lowest PEEP as possible. Keep driving pressures < 15 cmH2O.
Find the latest version at evms.edu/covidcare
■ Moderate sedation to prevent self-extubation
■ Trial of inhaled Flolan (epoprostenol)
■ Prone positioning
■ ?? ECMO < 60 yrs. and no severe commodities/organ failure.
There is widespread concern that using HFNC could increase the risk of viral transmission. There is however, no evidence to support this fear. HFNC is a better option for the patient and the health care system than intubation and mechanical ventilation. CPAP/BiPAP may be used in select patients, notably those with COPD exacerbation or heart failure.
A group of patients with COVID-19 deteriorates very rapidly (see graphic below). Intubation and mechanical ventilation may be required in these patients.
12. Treatment of secondary HLH (increasing Ferritin, CRP and transaminases)
■ “High dose corticosteroids.” Methylprednisolone 120 mg q 8 hourly for at least 3 days, then wean accruing to CRP, IL-6, Ferritin etc.
■ Tocilizumab (IL-6 inhibitor) as per dosing guideline.
■ Consider plasma exchange 13. Monitoring
■ Daily: PCT, CRP, IL-6, BNP, Troponins, Ferritin, Neutrophil-Lymphocyte ratio, D-dimer, Mg, CRP and Ferritin are good biomarkers and track disease severity. Thromboelastogram (TEG) on admission and repeated as indicated.
■ In patients receiving IV vitamin C, the Accu-ChekTM POC glucose monitor will result in spuriously high blood glucose values. Therefore, a laboratory glucose is recommended to confirm the blood glucose levels.
■ Monitor QTc interval if using chloroquine/hydrochloroquine and azithromycin and monitor Mg++ (torsades is uncommon in monitored ICU patients)
■ No routine CT scans, follow CXR and chest ultrasound.
■ Follow ECHO closely; Pts develop a severe cardiomyopathy. 14. Post ICU management
a. Enoxaparin 40-60 mg s/c daily
b. Methylprednisone 40 mg day, the wean slowly c. Vitamin C 500 mg PO BID
d. Melatonin 3-6 mg at night
END This section, concludes Dr. Paul Marik's suggested Protocol. Show this link or protocol for your doctor when you consult your own doctor. Marik-Covid-Protocol-Summary.pdf
This matches the program also recommended by Dr. Shiva Ayyadurai. His recomendation to President Trump is here as https://shiva4senate.com/immune-and-economic-health-for-america-coronavirus/.
After you have printed Dr. Marik's Protocol, go back and click the link above to see the recommended Vitamin regimen by Dr. Shiva. The link says shiva4senate, but don't worry, this link is for a copy of the letter to President Trump for how to protect the American People.
Please use these vitamins to prepare your immune system to defeat SARS-CoV-2 when you come into contact with it.. Don’t wait until you go to the hospital, since many doctors having 80 to 88% fatality rates in hospitals where they are putting patients on ventilators. The doctors having almost no deaths were not using ventilators but using Intravenous Vitamin C Therapy. The answer to the COVID-19 crisis is immune health. For a detailed explanation later, please read my other blog post in a 5 part series.
For now, I will print out the exact text from Dr. Paul Marik who has asked that this be provided to every family, government official, doctor, and medical facility in the U.S.
He has 3 parts. 1. Prophylaxis - what you need now. 2. Mildly Symptomatic or in Hospital not in ICU, and 3. Critical Condition in ICU.
The important takeaway is this: If you get seriously ill, do not allow yourself to be blindly put on a ventilator, tell your doctor you want to INSIST on Dr. Marik’s Recommended Protocol shown and on the link.
PRINT THIS LINK AND PROVIDE TO YOUR ADMITTING PHYSICIAN
https://www.evms.edu/media/evms_public/departments/internal_medicine/Marik-Covid-Protocol-Summary.pdf
EVERY WORD BELOW THIS LINE IS COPIED FROM THE LINK- THE EXACT WORDS OF DR. MARIK
Prophylaxis
While there is very limited data (and none specific for COVID-19), the following “cocktail” may have a role in the prevention/mitigation of COVID-19 disease, especially amongst the most vulnerable citizens in our community; i.e. those over the age of 60 years and those with medical comorbidities. While there is no high level evidence that this cocktail is effective; it is cheap, safe and should be readily available. So what is there to lose?
• Vitamin C 500 mg BID
• Zinc 75-100 mg/day (acetate, gluconate or picolinate; do not use for more than 2 months)
• Quercetin 500-1000 mg/day
• Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 1-2 mg at night
• Vitamin D3 1000-4000 iu/day (optimal dose unknown; likely that those with baseline low 25-OH
vitamin D and those > 40o latitude will benefit the most)
Mildly Symptomatic patients (at home):
■ Vitamin C 500mg BID
■ Quercetin 250-500 mg BID (if available)
■ Zinc 75-100 mg/day
■ Melatonin 6-12 mg at night (the optimal dose is unknown)
■ Vitamin D3 1000-4000 iu/day
■ Optional: Hydroxychloroquine 400mg BID day 1 followed by 200mg BID for 4 days
Hospitalized with Respiratory symptoms (SOB; hypoxia- requiring N/C ≥ 4 L min: admit
to ICU):Additional Treatment Components (the Full Monty)
Essential Treatment (dampening the STORM)
1. Methylprednisolone 80 mg loading dose then 40mg q 12 hourly for at least 7 days and until transferred out of ICU. Alterative approach: Hydrocortisone 50 mg q 6 hourly.
2. Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until transferred out of ICU. Note caution with POC glucose testing (see below).
General schema for respiratory support in patients with COVID-19
TRY TO AVOID INTUBATION IF POSSIBLE
Low-Flow Nasal Cannula
■ Typically set at 1-6 Liters/Min
High Flow Nasal Cannula (Limitation on Flow Rate)
■ Accept permissive hypoxemia (O2 Saturation > 86%)
■ Titrate FiO2 based on patient’s saturation
■ Accept flow rates of 60 to 80 L/min
■ Trial of inhaled Flolan (epoprostenol)
■ Attempt proning (cooperative proning)
Invasive Mechanical Ventilation
■ Target tidal volumes of ~6 cc/kg
■ Lowest driving pressure and PEEP
■ Sedation to avoid self-extubation
■ Trial of inhaled Flolan
Prone Positioning
■ Exact indication for prone ventilation is unclear
■ Consider in patients with PaO2/FiO2 ration < 150
VV-ECMO
■ Indications remain unclear
■ Early discussion with ECMO center or team may be advisable
3. Full anticoagulation: Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e 1 mg kg s/c q 12 hourly (dose adjust with
Cr Cl < 30mls/min). Heparin is suggested with CrCl < 15 ml/min. Alternative approach: Half-dose rTPA: 25mg of tPA over 2 hours followed by a 25mg tPA infusion administered over the subsequent 22 hours, with a dose not to exceed 0.9 mg/kg followed by full anticoagulation. On transfer to floor, consider reducing enoxaparin to 40-60 mg /day. Note: Early termination of ascorbic acid and corticosteroids will likely result in a rebound effect.
4. Melatonin 6-12 mg at night (the optimal dose is unknown).
5. Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. Prevent hypomagnesemia (which increases the cytokine storm and prolongs Qtc).
6. Optional: Azithromycin 500 mg day 1 then 250 mg for 4 days (has immunomodulating properties including downregulating IL-6; in addition Rx of concomitant bacterial pneumonia).
7. Optional: Atorvastatin 40-80 mg/day. Of theoretical but unproven benefit. Statins have been demonstrated to reduce mortality in the hyper-inflammatory ARDS phenotype. Statins have pleotropic anti-inflammatory, immunomodulatory, antibacterial and antiviral effects. In addition, statins decrease expression of PAI-1
8. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected based on procalcitonin levels and resp. culture (no bronchoscopy).
Co-infection with other viruses appears to be uncommon, however a full respiratory viral panel is still recommended. Superadded bacterial infection is reported to be uncommon (however, this may not be correct).
9. Maintain EUVOLEMIA (this is not non-cardiogenic pulmonary edema). Due to the prolonged “symptomatic phase” with flu-like symptoms (6-8 days) patients may be volume depleted. Cautious rehydration with 500 ml boluses of Lactate Ringers may be warranted, ideally guided by non-invasive hemodynamic monitoring. Diuretics should be avoided unless the patient has obvious intravascular volume overload.
10. Early norepinephrine for hypotension. While the angiotenin II agonist GiaprezaTM has a limited role in septic shock, this drug may uniquely be beneficial in patients with COVID-19 (downregulates ACE-2).
11. Escalation of respiratory support (steps); Try to avoid intubation if at all possible
■ Accept “permissive hypoxemia” (keep O2 Saturation > 84%)
■ N/C 1-6 L/min
■ High Flow Nasal canula (HFNC) up to 60-80 L/min
■ Trial of inhaled Flolan (epoprostenol)
■ Attempt proning (cooperative repositioning-proning; see Figure)
■ Intubation... by Expert intubator; Rapid sequence. No Bagging; Full PPE. Crash/emergency intubations should be avoided.
Volume protective ventilation; Lowest driving pressure and lowest PEEP as possible. Keep driving pressures < 15 cmH2O.
Find the latest version at evms.edu/covidcare
■ Moderate sedation to prevent self-extubation
■ Trial of inhaled Flolan (epoprostenol)
■ Prone positioning
■ ?? ECMO < 60 yrs. and no severe commodities/organ failure.
There is widespread concern that using HFNC could increase the risk of viral transmission. There is however, no evidence to support this fear. HFNC is a better option for the patient and the health care system than intubation and mechanical ventilation. CPAP/BiPAP may be used in select patients, notably those with COPD exacerbation or heart failure.
A group of patients with COVID-19 deteriorates very rapidly (see graphic below). Intubation and mechanical ventilation may be required in these patients.
12. Treatment of secondary HLH (increasing Ferritin, CRP and transaminases)
■ “High dose corticosteroids.” Methylprednisolone 120 mg q 8 hourly for at least 3 days, then wean accruing to CRP, IL-6, Ferritin etc.
■ Tocilizumab (IL-6 inhibitor) as per dosing guideline.
■ Consider plasma exchange 13. Monitoring
■ Daily: PCT, CRP, IL-6, BNP, Troponins, Ferritin, Neutrophil-Lymphocyte ratio, D-dimer, Mg, CRP and Ferritin are good biomarkers and track disease severity. Thromboelastogram (TEG) on admission and repeated as indicated.
■ In patients receiving IV vitamin C, the Accu-ChekTM POC glucose monitor will result in spuriously high blood glucose values. Therefore, a laboratory glucose is recommended to confirm the blood glucose levels.
■ Monitor QTc interval if using chloroquine/hydrochloroquine and azithromycin and monitor Mg++ (torsades is uncommon in monitored ICU patients)
■ No routine CT scans, follow CXR and chest ultrasound.
■ Follow ECHO closely; Pts develop a severe cardiomyopathy. 14. Post ICU management
a. Enoxaparin 40-60 mg s/c daily
b. Methylprednisone 40 mg day, the wean slowly c. Vitamin C 500 mg PO BID
d. Melatonin 3-6 mg at night
END This section, concludes Dr. Paul Marik's suggested Protocol. Show this link or protocol for your doctor when you consult your own doctor. Marik-Covid-Protocol-Summary.pdf
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