Out of Sight, Out of Mind, Right? Not in COVID-19 Shock or Anaerobic and Exhaustive Shock versus Septic Shock Dilemma That Means to Live or Die. Emergency Attention and a Necessity of Trials

Background: COVID-19 brought challenges that did not end after a two-year pandemic. From more straightforward changes in habits to studying to understand the enigmatic parasite-host relationship, we can better manage the patient infected with SARS-CoV-2 even with a vaccine full of doubts and antivirals that do not correctly cover the viral period. SARS-CoV-2 brought the chronic inflammation now called “The Long COVID-19 Syndrome” (LCS), something still little talked about, but we already see deaths due to non-identification of this inflammatory syndrome that can lead to shock. Theory: LCS Shock is due to a long period of metabolic stress, reflecting the shift from inflammation to oxidative stress and innate immunity, and does not respond to antimicrobials, as its main component is inflammatory, although there may be conjoined bacterial translocation. Thus, we are losing patients to a new syndrome confused with sepsis and septic shock. While septic shock (SS) responds to antimicrobials, Inflammatory Shock (ISc) does not respond to antimicrobials alone, requiring high doses of corticosteroids. Review: This study shows that we need to differentiate SS and ISC, as the treatment is different. The review shows that Lactate, LDH and the presence of new/recent cardiac changes and bradycardia in the face of a status where there should be tachycardia as the usual response can differ ISC from SS. Maybe the main responsible for high LDH is Warburg Effect. Conclusion: We have a dilemma that requires clinical studies that routinely match high doses of corticosteroids (until there is something better to be done) and bring laboratory and imaging differences to diagnose SS vs ISc better.

Methylprednisolone Pulse Therapy in COVID-19 as the First Choice for Public Health: When Right Timing Breaks Controversies—Emergency Guide

Based on Russian and the Middle East corticosteroids trials in MERS-CoV, we performed methylprednisolone pulse therapy (MPT), resulting in a clinical trial still without result. Our previous cohort (not compared n = 18) showed 76% of MPT patients did not progress to orotracheal intubation as MTP blocked the cytokine storm, a lower result compared to Tehran’s study explained by performing MPT in any lung phase. The Middle East study had been carried out during the initial lung phase. We are in an international emergency. Considering previous protocols and clinical practice, we understand that MPT must be used in COVID-19, and the indication to avoid going to the hospital when the first symptoms appear should be changed urgently for the population with inflammatory comorbidities. This article aims to: 1) show the Iranian protocol to reduce deaths and intubations by COVID-19;2) present a possible approach to the patient COVID-19 with methylprednisolone pulse and strict criteria for orotracheal intubation to avoid hypoxemia;3) highlight that there is already a protocol that can be an international guideline-based on the Iranian work for the treatment of COVID-19;and 4) argue that corticosteroids are not controversial, but their use in a period outside the best timing period makes it controversial;and 5) emphasise the urgency of modifying the current protocol that postpones the visit of patients to the hospital in case of symptoms, since late hospital evaluation has been catastrophic for a world population.