Summary of a hypothesis for Sars-Cov-2:

We now suspect that viral proteins attack the B1 subunit of hgb. This may effectively deactivate this subunit. If the virus does this to 100% of your hgb, this would leave you with an spO2 of 75%. This explains laughing on the phone at 75%

With only three, we are not taking advantage of the highest affinity binding site. This leaves us on the steep portion of the curve without our usual reserve and shifts the whole curve to the right. It also changes the shape of the sigmoid, less cooperation and steeper.

As the disease progresses, the covidsludge/pulmonary edema depending on who wins: ARDS vs HAPE, an argument now between NYC and most of the rest. This shunting further lowers the PaO2 and diffusion impairment further decreases the PaO2 and increases the A-a gradient.

Increasing FiO2 will increase the pAO2 back to normal and help correct hypoxemia. But remember, even if we are doing this to reduce or eliminate shunt, the hgb is bound by the virus and 75% could be as good as it gets.

If you get a sat higher than 75% this implies not all hgb is affected. You can not use FiO2 to increase beyond YOUR hgb’s capacity but it also increases the paO2—the partial pressure of the O2 dissolved in the blood.

We know that higher hgb levels is associated with worse outcomes and men have higher hgb levels (women also have higher levels of possibly protective 2,3dpg).

So the next series of questions are should we exchange transfuse. I believe the answer is no. If you transfuse more hgb (more m/m) and the viral protein binds it—it does not help and might hurt.

It might hurt because the viral—porphyrin moietey seems to allow the virus to more easily invade the fatty membranes of the epithelium anywhere, especially the alveoli. This potentially contributes to the prothrombotic effects which generally starts with endothelial injury.

If the cause of death is frequently complications from thrombosis then transfusion might make them more sick and promote thrombosis.

Perhaps leeches or bloodletting? Is anemia protective? HBO?

Does Thalassemia explain Italy? Glycosylated hgb appears to be more susceptible making it worse for diabetics and the elderly and also may cause labile glucose levels.

And does this make anticoagulation key?