TimesNewRoman

EM/CCM
May 14, 2013
2,953
3,144
Status
  1. Attending Physician
Looks like we are down to just decadron. Anyone going to stop using remdesivir?

wha wha what? An antiviral doesn’t work? Color me shocked.

We’ve protocolized our Covid icu pretty heavily. I suspect protocol will change within the next couple weeks.
 
Oct 10, 2007
2,364
848
Status
  1. Fellow [Any Field]
  2. Attending Physician
Ill probably still pull it out for younger people or people with no comorbidities who have a good shot at meaningful recovery but as a universal therapy for everyone who walks in the door requiring O2 I think it should die since it seems likely that it offers no benefit at large.
 
About the Ads
Oct 11, 2016
666
787
Status
  1. Attending Physician
The evidence for remdesivir has been poor all along especially for patients needing the vent/non-invasive support. The problem is most patients and their families want you to DO something and some specifically ask for remdesivir. I even had a family member ask me last week to give their loved one the regeneron monocolonal antibody. It is very challenging to convince a hard headed family member with a "nurse" friend that their loved one doesn't need remdesivir (or hydroxychloroquine or zinc or UV light wand up the ass).
 
Sep 27, 2008
2,161
698
Status
  1. Resident [Any Field]
Ill probably still pull it out for younger people or people with no comorbidities who have a good shot at meaningful recovery but as a universal therapy for everyone who walks in the door requiring O2 I think it should die since it seems likely that it offers no benefit at large.
Statements like this confuse me. Are you concerned about toxicity? I doubt young, non-comorbid patients in the ICU w/ severe hypoxemia are the ones benefiting from this drug.

Given that remdesivir really lacks any empirical backing, we're back to theoretical concerns. So I would say that our dear leader was the perfect candidate--old+risk factors and treated very early in the course.

Kudos to those of you with the balls to stop using it. My hospitals were full-steam ahead on hydroxychloroquine, so I don't foresee any changes to our protocols. Not a bad time to buy stock in Gilead, imho.
 
Oct 10, 2007
2,364
848
Status
  1. Fellow [Any Field]
  2. Attending Physician
Statements like this confuse me. Are you concerned about toxicity? I doubt young, non-comorbid patients in the ICU w/ severe hypoxemia are the ones benefiting from this drug.

Given that remdesivir really lacks any empirical backing, we're back to theoretical concerns. So I would say that our dear leader was the perfect candidate--old+risk factors and treated very early in the course.

Kudos to those of you with the balls to stop using it. My hospitals were full-steam ahead on hydroxychloroquine, so I don't foresee any changes to our protocols. Not a bad time to buy stock in Gilead, imho.

It is overall system cost--we cant afford to give a drug that costs 2.5k for everybody who walks in the door with this. If we admit 5% of the 8 million cases in the USA that is spending 1 billion dollars in healthcare money on a single drug that has shown no benefit. That is ridiculous.

Thankfully I have worked in a hospital that did not buy in to plaquenil and will hopefully stop using this routinely as well.
 
Sep 27, 2008
2,161
698
Status
  1. Resident [Any Field]
It is overall system cost--we cant afford to give a drug that costs 2.5k for everybody who walks in the door with this. If we admit 5% of the 8 million cases in the USA that is spending 1 billion dollars in healthcare money on a single drug that has shown no benefit. That is ridiculous.

Thankfully I have worked in a hospital that did not buy in to plaquenil and will hopefully stop using this routinely as well.
Sorry to be pedantic, but your two statements are incongruous. (I agree with the second, but your first one was illogical).

From a cost-benefit perspective, throwing the kitchen sink at someone on death's door is silly. A 30 year old on ecmo has far worse prognosis than a 74 year old w/ transient desaturation. Plus, based on everything we think we know about this disease, this drug is highly unlikely to offer anything to the former, but may result in modest benefit for the latter.
 
Oct 10, 2007
2,364
848
Status
  1. Fellow [Any Field]
  2. Attending Physician
Sorry to be pedantic, but your two statements are incongruous. (I agree with the second, but your first one was illogical).

From a cost-benefit perspective, throwing the kitchen sink at someone on death's door is silly. A 30 year old on ecmo has far worse prognosis than a 74 year old w/ transient desaturation. Plus, based on everything we think we know about this disease, this drug is highly unlikely to offer anything to the former, but may result in modest benefit for the latter.

You do critical care right? A 30 year old can have 40+ years life expectancy vs less than 10 in a 74 year old. Of course they deserve more resources. Most places wouldn't even offer ecmo to someone over 70.

I don't think it is discordant to say that an expensive drug of limited utility might be better used in rare cases that develop disproportionately severe disease with no risk factors as opposed to everyone who walks on the door. I wouldn't fault someone for not doing it but I would fault someone for using it ok n everyone given what we know now.
 
Sep 27, 2008
2,161
698
Status
  1. Resident [Any Field]
No, I'm EM.

Look we're obviously talking past each other. What I was trying to convey, is that the typical patient put on ecmo for ARDS has a very poor prognosis--likely much worse than an elderly patient with mild covid19.

It seems like you think I have a far less sophisticated understanding of cost-benefit analysis than I possess. But going back to my first question, why would you think a young patient in the ICU would be the best candidate for this drug?
 
Oct 10, 2007
2,364
848
Status
  1. Fellow [Any Field]
  2. Attending Physician
It seems like you think I have a far less sophisticated understanding of cost-benefit analysis than I possess. But going back to my first question, why would you think a young patient in the ICU would be the best candidate for this drug?

Why do you say that?

You are missing the lack of comorbidities part. I'm not saying every obese young person in the icu should qualify, but rather the ones who might have a high viral load causing them to get sick where this might actually do something as opposed to it being a function of the immune system.

Why do you think the low risk 75 year old who is going to be fine needs a 2.5k drug?
 

TimesNewRoman

EM/CCM
May 14, 2013
2,953
3,144
Status
  1. Attending Physician
Why do you say that?

You are missing the lack of comorbidities part. I'm not saying every obese young person in the icu should qualify, but rather the ones who might have a high viral load causing them to get sick where this might actually do something as opposed to it being a function of the immune system.

Why do you think the low risk 75 year old who is going to be fine needs a 2.5k drug?

What I do with the vent, fluid management, sedation, etc have 100x more impact than the new tamilfu.
 
  • Like
Reactions: aafisahar
Oct 10, 2007
2,364
848
Status
  1. Fellow [Any Field]
  2. Attending Physician
What I do with the vent, fluid management, sedation, etc have 100x more impact than the new tamilfu.

Ok? Nobody is arguing good critical care isn't important here. I think if you've taken care of a bunch of these people though a certain degree of hopelessness sinks in since they all stay sick forever even when you do everything right. Its why so many people have been grasping for a tool to use.
 

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.
About the Ads