Coronavirus thread

[45dotACP]

I remember when early reports were still coming out of China that they experienced very high rates of VAPs that most attributed to their use of IV steroids, not surprised it's happening if he's blasting them with steroids to effect.

Is the IV UFH drip particular to your institution? I haven't heard of any guidelines re: anticoagulation for COVID patients, but I haven't been paying very close attention either.

Our hospital used weight based heparin nomograms for COVID patients if their D-dimer levels are too high.

We seem to have migrated to subQ lovenox for patients whose renal function is OK.

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[Guinnessman]

My wife just received results from her COVID test, a big fat negative. Her symptoms are fatigue, muscle aches, and fever. I am taking my oldest for a test tomorrow since she has the same symptoms as Mamacita. 😜

So far my youngest and I have no symptoms aside from her wearing me out. This kid goes nonstop.🤣

[Sensei]

I remember when early reports were still coming out of China that they experienced very high rates of VAPs that most attributed to their use of IV steroids, not surprised it's happening if he's blasting them with steroids to effect.

Is the IV UFH drip particular to your institution? I haven't heard of any guidelines re: anticoagulation for COVID patients, but I haven't been paying very close attention either.

There have been anecdotal and retrospective reports of thrombosis associated with COVID-19. This includes higher rates of VTE, increased ACS/CVA risk, and frequent circuit and vascular clots in patients receiving CRRT or ECMO. Overall, I’d say that the quality of evidence for this is poor and conflicting across the spectrum of severity. However, the culture at many institutions is to anticoagulate ICU patients at various intensities. This is especially true with VV-ECMO where a target PTT of at least 40-50 might prolong the oxygenator or prevent DVT from cannulas (https://nvic.nl/sites/nvic.nl/files/pdf/review_22.pdf).

Interestingly, a collection of 3 trials aimed at answering this question in ICU patients were halted after an interim analysis suggested futility and possibly harm.

https://www.nih.gov/news-events/news...id-19-patients

[Sensei]

Thanks for the answer. Any idea on the survival rate of covid patients who end up needing MCS or ECMO in your hospital? Does your previous post also mean that if somebody shows up with a heart attack and needs mcs before surgery they’re screwed?

@Sensei and @Nephrology have y’all seen any numbers on covid survival after the patient needs MCS ?

Our outcomes are nowhere near this good since I arrived at one of the nation’s largest ECLS programs in mid-pandemic: https://www.thelancet.com/journals/l...008-0/fulltext

I’ve made 3 patients on ECMO DNR-comfort care in the past 2 weeks I’ve only seen 1 patient with COVID survive decannulation since this summer (I’ve cared for 8 over the past 2 months), and that one is nowhere near being out of the woods.

I get the sense that our ECLS leadership is dissatisfied with our outcomes in this recent wave since the Summer/Fall. We originally slotted 12 beds in the for VV ECMO, but this got paired back to 8 due to “staffing shortages.” Our last VV cannulation was 3 weeks ago, and I’m told that we are turning down requests from other hospitals every day. I recall being told that hospitals generally make money on ECMO up until about day 7-9. Something tells me that the 4-6 weeks on pump only to die is souring our leadership’s test for more ECMO.

[Caballoflaco]

Our outcomes are nowhere near this good since I arrived at one of the nation’s largest ECLS programs in mid-pandemic: https://www.thelancet.com/journals/l...008-0/fulltext

I’ve made 3 patients on ECMO DNR-comfort care in the past 2 weeks I’ve only seen 1 patient with COVID survive decannulation since this summer (I’ve cared for 8 over the past 2 months), and that one is nowhere near being out of the woods.

I get the sense that our ECLS leadership is dissatisfied with our outcomes in this recent wave since the Summer/Fall. We originally slotted 12 beds in the for VV ECMO, but this got paired back to 8 due to “staffing shortages.” Our last VV cannulation was 3 weeks ago, and I’m told that we are turning down requests from other hospitals every day. I recall being told that hospitals generally make money on ECMO up until about day 7-9. Something tells me that the 4-6 weeks on pump only to die is souring our leadership’s test for more ECMO.

Damn, sometimes I wish we had a dislike button.

[Sensei]

Damn, sometimes I wish we had a dislike button.

My personal experience with treating more than 100 critically ill patients with COVID (8 on VV ECMO) is that patients who get sick as piss in a couple of days often recover quickly. That happened to one of my friends - room air to 60L high-flow nasal cannula within 24 hours, then back to 2L within 36 hours, and discharged a day later. He is 45 and in great shape. The ones that get mildly sick, and then bounce up and down for a week or two before eventually getting intubated are screwed. Keep in mind that we’ve known that cannulation for VV ECMO after about 7 days is associated with poor outcomes.

Most (all?) of our VV ECMOs are age 45-60 who slowly deteriorated over 7-10 days before being cannulated. They generally have BMIs of 25-35...

[Caballoflaco]

My personal experience with treating more than 100 critically ill patients with COVID (8 on VV ECMO) is that patients who get sick as piss in a couple of days often recover quickly. That happened to one of my friends - room air to 60L high-flow nasal cannula within 24 hours, then back to 2L within 36 hours, and discharged a day later. He is 45 and in great shape. The ones that get mildly sick, and then bounce up and down for a week or two before eventually getting intubated are screwed. Keep in mind that we’ve known that cannulation for VV ECMO after about 7 days is associated with poor outcomes.

Most (all?) of our VV ECMOs are age 45-60 who slowly deteriorated over 7-10 days before being cannulated. They generally have BMIs of 25-35...

I appreciate the details and learning continues to occur, but honestly my last post was more about what you med folks who are treating these patients are dealing with than it was about the patients themselves.

Here, do this resource intensive intervention that hasn’t been shown to actually help people recover, but lets them linger for weeks in the land between life and death seems like a shitty job assignment to this layman.

[YVK]

There have been anecdotal and retrospective reports of thrombosis associated with COVID-19. This includes higher rates of VTE, increased ACS/CVA risk, and frequent circuit and vascular clots in patients receiving CRRT or ECMO. Overall, I’d say that the quality of evidence for this is poor and conflicting across the spectrum of severity.

We're seeing an anecdotal evidence of massive thrombus burden in Covid MI patients. We've not had a lot of Covid patients with STEMIs but those that we had all have been sad stories.

[Borderland]

Just a question because this seems really weird to me. India has a population 4X higher than the US yet it's covid cases are half that of the US. Recently their case numbers have been dropping where US numbers are spiking. Deaths are also less than half the US.

Do they have a better health care system or does it have something to do with the way the US has handled the virus. I thought India was a 3rd world country.

[TGS]

Just a question because this seems really weird to me. India has a population 4X higher than the US yet it's covid cases are half that of the US. Recently their case numbers have been dropping where US numbers are spiking. Deaths are also less than half the US.

Do they have a better health care system or does it have something to do with the way the US has handled the virus. I thought India was a 3rd world country.

This is common with third world countries regarding outbreaks, and not isolated to Covid or India....reporting of disease can often be inversely proportional to the economic development. @Nephrology and I were talking about this a few weeks ago.

The reporting mechanisms in third world countries are unable to accurately test and track these sorts of things, and the population is generally oblivious as well. If you get sick, more often than not you stay it out at home and either die or get better. When reporting is accurate (such as AIDS in Africa), it's often due to emphasis programs from foreign aid/NGOs. Africa, for example.....if there was no internationally funded/executed AIDS program across Africa that could enable the countries to accurately asses the situation, the numbers would probably show San Francisco has having more AIDS than the entire African continent. That wouldn't mean that AIDS didn't exist in Africa, it would mean that they're unable (or unwilling) to track it.

I currently live in an undeveloped area with abysmal public health infrastructure and a wide distrust of modern medicine among the local population (Polio still exists here, one of only 3 places in the world to claim such a title). When crunching the numbers, it's blatantly apparent that they simply don't have an accurate count of cases; especially given how we've lost 39 doctors in our province alone to covid (up from the 26 that I reported to Neph a few weeks ago), we should have exponentially more reported covid cases (or exponentially less dead doctors).