Treating COVID pre and post intubation

[MedicineZ0Z]

Anecdotally it seems like we have two categories of treatments.

1. Hydroxychloroquine +/- azithromycin.

2. Xeljanz/Anakinra/Tocilizumab.

The first category is treating the virus and superimposed bacteria. The second category is treating the cytokine storm and quite useful for when the patient is in ARDS. I think it's a reasonable school of thought that the first category should be used early (outpatients and early inpatient) and the second category should be the primary treatment modality for those who are tubed. Treating the virus once tubed probably isn't going to induce a dramatic turnaround, it needs to be stopped early on.

Thoughts??

(and aware we're still waiting on remdesivir)

---

Members don't see this ad.

 

[CCM-MD]

My n=1 vented patient is on remdesivir and hydroxychloroquine. Lets call these therapies what they are: experimental. We are all speculating benefit based on limited evidence. Not doing further harm to our patients should be our number one priority. I would be worried about using immunotherapeutics in any of my patients until I saw some better evidence. My thoughts are, focus on good supportive care in those who are not yet critically ill and good overall critical care management in those who are critically ill. Hopefully, we can get more evidence on these therapies soon but I am not optimistic for a drug that changes outcome significantly - we barely have drugs for influenza and it has been around forever.

 

[MedicineZ0Z]

My n=1 vented patient is on remdesivir and hydroxychloroquine. Lets call these therapies what they are: experimental. We are all speculating benefit based on limited evidence. Not doing further harm to our patients should be our number one priority. I would be worried about using immunotherapeutics in any of my patients until I saw some better evidence. My thoughts are, focus on good supportive care in those who are not yet critically ill and good overall critical care management in those who are critically ill. Hopefully, we can get more evidence on these therapies soon but I am not optimistic for a drug that changes outcome significantly - we barely have drugs for influenza and it has been around forever.

Immunotherapeutics are being used in many places with anecdotal success. Realistically, are these vented patients on antivirals going to get off the vent and live a normal life? Hypothetical but if your odds of survival are.. lets say 40%. It's reasonable to take an experimental shot at something that has anecdotal success.

 

[deleted171991]

I think the number one thing we all need to remember is that this is a bad pneumonia with ARDS, possibly followed by a cytokine storm and various degrees of MODS. So the usual BASICS apply (before any wise, non-evidence-based, interventions):

1. (Non)invasive, high PEEP, lung-protective ventilation and FiO2, proning, inhaled PG.
2. Keeping the patient dry as a bone (that includes diuretics for all the crap we infuse into them). The last thing they need is interstitial lung water, or a fluid-overloaded heart.
3. Keeping the heart rate under control, meaning under 100, even with an esmolol drip if needed, unless it worsens tissue hypoxia. This is a two-week stress-test for the heart and lungs; it's a marathon, not a sprint.
4. Keeping fever under control, meaning under 101.3. Fever is one of the few things that help us against unknown viruses, as long as it does not cause AMS and cardiorespiratory functional overload. If it does, kill IT (not the patient), preferably with tylenol or physical cooling.
5. Keeping the patient minimally fed, or preferably NPO, especially if obese with big bellies and small lungs, or reduced cardiorespiratory reserve at baseline.
6. Keeping sugars under control (much easier while NPO). Minimizing insulin resistance and secretion, such a nice hormone that stimulates epi release and decreases immunity, the last thing we need.
7. Avoiding iatrogenesis at all price. Doing no harm first (and second, and third). Not persisting in mistakes.
8. Minimizing antibiotics unless signs of bacterial disease.
9. Frequent checks on the patient with many rapid evidence (e.g. US) based interventions, as needed, like anesthesiologists in the OR, instead of the lazy rounding 2-3 times/day (or less).
10. QUIET AND DARK AT NIGHT, LET PEOPLE SLEEP AS MUCH AS POSSIBLE. NO ALARMS, NO TALKING. Group patients geographically based on the need for interventions at night. TIRED PATIENTS HAVE CRAPPY IMMUNITY. KEEP PATIENTS AS HAPPY, WARM AND COMFORTABLE AS POSSIBLE. QUALITY BASIC NURSING.

So many people ignore some of these, and then they blame the disease/patient for dying. On top of this, come the Covid-specific issues, such as the pro-thrombotic state, the cytokine storm, the cardiomyopathy, the multiple rebounds, the rapid worsening, the anecdotal treatments etc.

Feel free to add to this list.

 

[CCM-MD]

I think the number one thing we all need to remember is that this is a bad pneumonia with ARDS, possibly followed by a cytokine storm and various degrees of MODS. So the usual BASICS apply (before any wise, non-evidence-based, interventions):

1. (Non)invasive, high PEEP, lung-protective ventilation and FiO2, proning, inhaled PG.
2. Keeping the patient dry as a bone (that includes diuretics for all the crap we infuse into them). The last thing they need is interstitial lung water, or a fluid-overloaded heart.
3. Keeping the heart rate under control, meaning under 100, even with an esmolol drip if needed, unless it worsens tissue hypoxia. This is a two-week stress-test for the heart and lungs; it's a marathon, not a sprint.
4. Keeping fever under control, meaning under 101.3. Fever is one of the few things that help us against unknown viruses, as long as it does not cause AMS and cardiorespiratory functional overload. If it does, kill IT (not the patient), preferably with tylenol or physical cooling.
5. Keeping the patient minimally fed, or preferably NPO, especially if obese with big bellies and small lungs, or reduced cardiorespiratory reserve at baseline.
6. Keeping sugars under control (much easier while NPO). Minimizing insulin resistance and secretion, such a nice hormone that stimulates epi release and decreases immunity, the last thing we need.
7. Avoiding iatrogenesis at all price. Doing no harm first (and second, and third). Not persisting in mistakes.
8. Minimizing antibiotics unless signs of bacterial disease.
9. Frequent checks on the patient with many rapid evidence (e.g. US) based interventions, as needed, like anesthesiologists in the OR, instead of the lazy rounding 2-3 times/day (or less).
10. QUIET AND DARK AT NIGHT, LET PEOPLE SLEEP AS MUCH AS POSSIBLE. NO ALARMS, NO TALKING. Group patients geographically based on the need for interventions at night. TIRED PATIENTS HAVE CRAPPY IMMUNITY.

So many people ignore some of these, and then they blame the disease/patient for dying. On top of this, come the Covid-specific issues, such as the pro-thrombotic state, the cytokine storm, the cardiomyopathy, the multiple rebounds, the rapid worsening, the anecdotal treatments etc.

Feel free to add to this list.

#11: Pray to whatever supernatural being you believe in, if you believe in one.

Immunotherapeutics are being used in many places with anecdotal success. Realistically, are these vented patients on antivirals going to get off the vent and live a normal life? Hypothetical but if your odds of survival are.. lets say 40%. It's reasonable to take an experimental shot at something that has anecdotal success.

Might not be reasonable if its hurting your patient. I need to see more before I start using those. #1 limit your own exposure. #2 don't hurt your patient. #3 good critical care management - much of which is excellently described in the post above.

 

[MedicineZ0Z]

#11: Pray to whatever supernatural being you believe in, if you believe in one.



Might not be reasonable if its hurting your patient. I need to see more before I start using those. #1 limit your own exposure. #2 don't hurt your patient. #3 good critical care management - much of which is excellently described in the post above.

This is primarily a genuine question. But at what prognosis would you be willing to try things that are being done experimentally at other centers?

 

[CCM-MD]

This is primarily a genuine question. But at what prognosis would you be willing to try things that are being done experimentally at other centers?

Tough question, hard to put that into words but there are definitely patients in which I would consider. AND my first patient is already on remdesivir and hydroxychloroquine - both experimental therapies and one is even endorsed by Dr. Donald Trump!

 

[MedicineZ0Z]

Tough question, hard to put that into words but there are definitely patients in which I would consider. AND my first patient is already on remdesivir and hydroxychloroquine - both experimental therapies and one is even endorsed by Dr. Donald Trump!

I assume the remdesivir was compassionate use? Which one did you start first and what changes did you see with each?

 

[CCM-MD]

I assume the remdesivir was compassionate use? Which one did you start first and what changes did you see with each?

Patient was started on hydroxychloroquine before ICU admission. Remdesivir started post intubation, and yes compassionate use. Hard to pinpoint what is making the patient better or preventing them from getting worse, when we are doing multiple things simultaneously. I have not seen a significant change with initiation of remdesivir. Would the patient be better/worse without it? Who knows, more data will tell.

 

[deleted171991]

To all the people who are using hydroxychloroquine and other untested meds, based on micro trials and hearsay, a terse reminder:

1. A TON of people were killed by aspirin toxicity in the Spanish flu pandemic. The mortality among people treated by homeopaths was 30 times smaller than among people treated by doctors. And we KNOW that homeopathy is placebo.
2. There were millions of people around the world harmed by useless blood transfusions and invasive procedures, based on a single community hospital study about Early Goal-Directed Therapy in Sepsis. Later it was also shown that the main author had financial interests in the medication/equipment touted in the study. It took almost 20 years and 3 huge international RCTs to prove it wrong.
3. Just because the monkey next to you scratches his arse, you shouldn't do it, too. You're a scientist. The world is full of bad doctors, despite their good intentions.
4. Just because it makes sense, based on our current limited understanding of the human body, it doesn't mean it will help. They used to think the same way about bloodletting. Even in vitro results cannot be translated to in vivo, most of the time.
5. You should tell your patients all of this. They need INFORMED consent. They need to understand that YOU MAY BE KILLING THEM. In those terms, not BS euphemisms. When we are playing with the immune system in a Covid-19 patient, we are playing with fire.

Just food for thought.

 

[CCM-MD]

To all the people who are using hydroxychloroquine and other untested meds, based on micro trials and hearsay, a terse reminder:

1. A TON of people were killed by aspirin toxicity in the Spanish flu pandemic. The mortality among people treated by homeopaths was 30 times smaller than among people treated by doctors. And we KNOW that homeopathy is placebo.
2. There were millions of people around the world harmed based on a single community hospital study about Early Goal-Directed Therapy in Sepsis. Later it was also shown that the main author had financial interests in the medication/equipment touted in the study. It took almost 20 years and 3 huge international RCTs to prove it wrong.
3. Just because the monkey next to you scratches his arse, you shouldn't do it, too. You're a scientist. The world is full of bad doctors; they are all around you.
4. Just because it makes sense, based on our current limited understanding of the human body, it doesn't mean it will help. They used to think the same way about bloodletting. Even in vitro results cannot be translated to in vivo, most of the time.
5. You should tell your patients all of this. They need INFORMED consent. They need to understand that YOU MAY BE KILLING THEM. In those terms, not BS euphemisms. When we are playing with the immune system, we are playing with fire.

Just food for thought.

I 100% agree with you. "But if it makes sense isn't it reasonable to try?" is a horrible argument. WE HAVE SEEN this movie before: single center trial proves benefit, later found to be non-beneficial in a larger trial. The reports for these drugs are not even single center trials, they are mostly case reports. Under more normal circumstances I would not even consider using any of these, but given we are in uncharted territory... in some instances may be reasonable to use.

Are you personally using any of these meds on any of your COVIDs?

 

[deleted171991]

I 100% agree with you. "But if it makes sense isn't it reasonable to try?" is a horrible argument. WE HAVE SEEN this movie before: single center trial proves benefit, later found to be non-beneficial in a larger trial. The reports for these drugs are not even single center trials, they are mostly case reports. Under more normal circumstances I would not even consider using any of these, but given we are in uncharted territory... in some instances may be reasonable to use.

Are you personally using any of these meds on any of your COVIDs?

I am not treating COVIDs yet, but I have seen hospitals around me putting HCQ or antivirals on their Covid treatment algorithm, as a rule, not as an experimental treatment, which is ridiculous.

 

[LADoc00]

Never in my time on this site have I had any interest in checking the CCU section of SDN and now Im looking at it at everyday..

Am reading the CFRs right from the Hopkins site?: Operations Dashboard for ArcGIS

as it appears our CCU folks here in the US are doing phenomenally well in keeping the death rates down.

Well done, well done.

 

[CCM-MD]

I am not treating COVIDs yet, but I have seen hospitals aroound me putting HCQ or antivirals on their Covid treatment algorithm, as a rule, which is ridiculous.

Considering a biologic is even more ridiculous.

 

[deleted171991]

Never in my time on this site have I had any interest in checking the CCU section of SDN and now Im looking at it at everyday..

Am reading the CFRs right from the Hopkins site?: Operations Dashboard for ArcGIS

as it appears our CCU folks here in the US are doing phenomenally well in keeping the death rates down.

Well done, well done.

It's just early days.

One of these days the mortality will jump so much that we'll have to clean our eyeglasses to believe it. That will be the day we will have been overwhelmed, like the Italians.

 

[LADoc00]

It's just early days.

One of these days the mortality will jump so much that we'll have to clean our eyeglasses to believe it. That will be the day we will have been overwhelmed, like the Italians.

But its the early days for everyone outside China essentially.
If you compare CFRs across nations, the

US has now 30,285 confirmed positives with a death toll of only 389, a total CFR of 1.3%

Italy has 53,578 cases with 4,825 deaths............9% CFR, or a massive 592% increase from the U.S.
Spain: 28.603 cases with 1756 death..................6.1% CFR
U.K.: 5,071 cases with 234 deaths........................4.6% CFR
France: 14,485 cases with 562 deaths................3.9% CFR, the best of the bunch and still a 200% increase from our rate.

Assuming, Spain, France and the U.K. are similarly operating in a "non-overwhelmed" mode they might be even HIGHER than Italy, especially the U.K. as it has among the lowest ICU beds per capita in the EU.

If this isnt a total win for American Healthcare and our CCU folks, which supposedly suck and are far to expensive according to some politicians, Im not sure what is.

More to come of course, but right now we are kicking arse and taking names.

 

[deleted171991]

But its the early days for everyone outside China essentially.
If you compare CFRs across nations, the

US has now 30,285 confirmed positives with a death toll of only 389, a total CFR of 1.3%

Italy has 53,578 cases with 4,825 deaths............9% CFR, or a massive 592% increase from the U.S.
Spain: 28.603 cases with 1756 death..................6.1% CFR
U.K.: 5,071 cases with 234 deaths........................4.6% CFR
France: 14,485 cases with 562 deaths................3.9% CFR, the best of the bunch and still a 200% increase from our rate.

Assuming, Spain, France and the U.K. are similarly operating in a "non-overwhelmed" mode they might be even HIGHER than Italy, especially the U.K. as it has among the lowest ICU beds per capita in the EU.

If this isnt a total win for American Healthcare and our CCU folks, which supposedly suck and are far to expensive according to some politicians, Im not sure what is.

More to come of course, but right now we are kicking arse and taking names.

You don't get it.

We can talk some more when our system will be as overwhelmed as the Italian one in Lombardy (in cases per capita, in a small region). We have not seen ANYTHING that comes close to that yet. The Italians are weeks ahead of us, even ahead of the rest of Europe. We are still under our healthcare system's limit.

There is NOTHING special the American intensivists (and I am one of them) will be able to do that the Italians in Lombardy didn't. They have the same tools we have, and they are better trained than us (their anesthesiology + multidisciplinary ICU training is the best combo). If anything, I have never seen those clever CPAP(?) bubbles they are using.

This epidemic will not be defeated in the ICUs. It will be defeated by meticulous testing, tracking and isolation.

 

[MedicineZ0Z]

Patient was started on hydroxychloroquine before ICU admission. Remdesivir started post intubation, and yes compassionate use. Hard to pinpoint what is making the patient better or preventing them from getting worse, when we are doing multiple things simultaneously. I have not seen a significant change with initiation of remdesivir. Would the patient be better/worse without it? Who knows, more data will tell.

How long before ICU admission? Were they already hospitalized? I think it's very reasonable to think that any anti-viral therapy will only be useful if given very early.

 

[MedicineZ0Z]

To all the people who are using hydroxychloroquine and other untested meds, based on micro trials and hearsay, a terse reminder:

1. A TON of people were killed by aspirin toxicity in the Spanish flu pandemic. The mortality among people treated by homeopaths was 30 times smaller than among people treated by doctors. And we KNOW that homeopathy is placebo.
2. There were millions of people around the world harmed by useless blood transfusions and invasive procedures, based on a single community hospital study about Early Goal-Directed Therapy in Sepsis. Later it was also shown that the main author had financial interests in the medication/equipment touted in the study. It took almost 20 years and 3 huge international RCTs to prove it wrong.
3. Just because the monkey next to you scratches his arse, you shouldn't do it, too. You're a scientist. The world is full of bad doctors, despite their good intentions.
4. Just because it makes sense, based on our current limited understanding of the human body, it doesn't mean it will help. They used to think the same way about bloodletting. Even in vitro results cannot be translated to in vivo, most of the time.
5. You should tell your patients all of this. They need INFORMED consent. They need to understand that YOU MAY BE KILLING THEM. In those terms, not BS euphemisms. When we are playing with the immune system in a Covid-19 patient, we are playing with fire.

Just food for thought.

True, but we also understand drugs much better now. HCQ has been around forever and coronaviruses aren't a brand new entity either. You have to weigh your risk of harm vs your risk of death by doing nothing and risk of lung fibrosis among other complications. If you think the HCQ has a lower risk, you have nothing to lose by trying it. Otherwise you're rolling the dice and by the time the clinical trials are done; your PFTs will be garbage.


As for biologics being used (successfully but anecdotal); I'm sure it's because of a worsening prognosis. Again, at what point do you try something novel? If you only had a 25% chance of survival, would you take those odds and run with it or want something with anecdotal success to be experimented on you?

 

[deleted171991]

But its the early days for everyone outside China essentially.
If you compare CFRs across nations, the

US has now 30,285 confirmed positives with a death toll of only 389, a total CFR of 1.3%

Italy has 53,578 cases with 4,825 deaths............9% CFR, or a massive 592% increase from the U.S.
Spain: 28.603 cases with 1756 death..................6.1% CFR
U.K.: 5,071 cases with 234 deaths........................4.6% CFR
France: 14,485 cases with 562 deaths................3.9% CFR, the best of the bunch and still a 200% increase from our rate.

Assuming, Spain, France and the U.K. are similarly operating in a "non-overwhelmed" mode they might be even HIGHER than Italy, especially the U.K. as it has among the lowest ICU beds per capita in the EU.

If this isnt a total win for American Healthcare and our CCU folks, which supposedly suck and are far to expensive according to some politicians, Im not sure what is.

More to come of course, but right now we are kicking arse and taking names.

And here's the confirmation of what I was saying above:

Israeli doctor in Italy: No. of patients rises but we get to everyone

Dr. Gai Peleg told Israeli television that in northern Italy, patients over 60 tend to receive less treatment with anesthesia and artificial respiratory machines.

www.jpost.com

 

[CCM-MD]

True, but we also understand drugs much better now. HCQ has been around forever and coronaviruses aren't a brand new entity either. You have to weigh your risk of harm vs your risk of death by doing nothing and risk of lung fibrosis among other complications. If you think the HCQ has a lower risk, you have nothing to lose by trying it. Otherwise you're rolling the dice and by the time the clinical trials are done; your PFTs will be garbage.


As for biologics being used (successfully but anecdotal); I'm sure it's because of a worsening prognosis. Again, at what point do you try something novel? If you only had a 25% chance of survival, would you take those odds and run with it or want something with anecdotal success to be experimented on you?

A lot of hypotheticals and speculation. I don't even have enough evidence accurately gauge someone's % chance of survival from this thing, so I don't know what to say to that. It is all risk/benefit and there will be situations where back is to the wall but may be too late for anything to have a meaningful impact at that point anyway. All I have to say is remember our oath: primum non nocere.

 

[turkeyjerky]

You don't get it.

We can talk some more when our system will be as overwhelmed as the Italian one in Lombardy (in cases per capita, in a small region). We have not seen ANYTHING that comes close to that yet. The Italians are weeks ahead of us, even ahead of the rest of Europe. We are still under our healthcare system's limit.

There is NOTHING special the American intensivists (and I am one of them) will be able to do that the Italians in Lombardy didn't. They have the same tools we have, and they are better trained than us (their anesthesiology + multidisciplinary ICU training is the best combo). If anything, I have never seen those clever CPAP(?) bubbles they are using.

This epidemic will not be defeated in the ICUs. It will be defeated by meticulous testing, tracking and isolation.

The other thing to consider is that we are very early in our epidemic. People might take a week or two to die, so CFRs early on will be an underestimate. As of today, we have 43k cases and 557 deaths w/o data on recovered cases.

 

[ShockIndex]

If anything, I have never seen those clever CPAP(?) bubbles they are using.

I though they were just hoods to limit aerosols from HFNC. Does anyone know for sure about the Buzz Lightyear helmets that the Italians are using.

 

[AnesthAnon]

It's a CPAP Helmet. Used for hypoxic respiratory failure and acute cardiogenic pulmonary edema.

 

[ShockIndex]

It's a CPAP Helmet. Used for hypoxic respiratory failure and acute cardiogenic pulmonary edema.

Thanks. I’ve never seen one in the States. I’ll read up tonight. Presumably there is less aerosols than with a mask.

 

[leviathan]

But its the early days for everyone outside China essentially.
If you compare CFRs across nations, the

US has now 30,285 confirmed positives with a death toll of only 389, a total CFR of 1.3%

Italy has 53,578 cases with 4,825 deaths............9% CFR, or a massive 592% increase from the U.S.
Spain: 28.603 cases with 1756 death..................6.1% CFR
U.K.: 5,071 cases with 234 deaths........................4.6% CFR
France: 14,485 cases with 562 deaths................3.9% CFR, the best of the bunch and still a 200% increase from our rate.

Assuming, Spain, France and the U.K. are similarly operating in a "non-overwhelmed" mode they might be even HIGHER than Italy, especially the U.K. as it has among the lowest ICU beds per capita in the EU.

If this isnt a total win for American Healthcare and our CCU folks, which supposedly suck and are far to expensive according to some politicians, Im not sure what is.

More to come of course, but right now we are kicking arse and taking names.

Now 1.7%, 2391 with 135,957 cases, and of course a lot of the 135k cases will have mortality that isn't accounted for yet. Mortality will also go much much higher if health care resources are overwhelmed and we have to start triaging like the Italians are doing.

 

[MedicineZ0Z]

And HCQ is now FDA approved.

Remember folks, HCQ needs to be given asap on day 1. Not when you're intubated or in the hospital. Our outpatients need it the second that test is positive.

 

[deleted171991]

And HCQ is now FDA approved.

Remember folks, HCQ needs to be given asap on day 1. Not when you're intubated or in the hospital. Our outpatients need it the second that test is positive.

Don't forget Holy Water on the side, and, beyond all, a touch of homeopathy. Even that may be better than HCQ, which hasn't been proven to do anything special for Covid-19 (and seems to have been proposed/overhyped by a very suspicious French "researcher").

During the 1918 flu pandemic, the mortality rate for patients treated with homeopathy was 30 times lower than for "modern" medicine. Back then, the "doctors" were killing people with unrecognized Bayer Aspirin toxicity (30 g/day). They confused the toxicity with viral pathology.

Nowadays, it seems HCQ is the "modern" drug (nobody seems to have heard of QT prolongation and VTach, especially during a myocarditis, especially when paired with azithromycin, even when patients code left and right in the same ICU). Deja vu? It seems that the "doctors" never change, even at big and famous cacademic centers.

I am only saying that we should be more SKEPTICAL, until we have evidence. It is hard, but that's why we are DOCTORS, not hoi-polloi. Not everything that shines is gold. FIRST DO NO HARM!

 

[CCM-MD]

And HCQ is now FDA approved.

This. Changes. Everything.

 

[SurfingDoctor]

And HCQ is now FDA approved.

Remember folks, HCQ needs to be given asap on day 1. Not when you're intubated or in the hospital. Our outpatients need it the second that test is positive.

So it’s as useless as Tamiflu. Got it.

 

[MedicineZ0Z]

So it’s as useless as Tamiflu. Got it.

The point is to improve your odds, reduce duration and severity of symptoms etc. We have very few definitive anti viral cures.

The biggest mistake with these things is starting it once the patient is in the hospital. It needs to be done the second the pre-test probability is high and no later than when the test is positive. Even for healthy outpatients. Saving it for when they're tubed is just silly. The virus is the least of your worries at that point.

 

[deleted171991]

The point is to improve your odds, reduce duration and severity of symptoms etc. We have very few definitive anti viral cures.

How do you improve your odds by giving a QT-prolonging drug in a disease that regularly causes various cardiac injuries, up to sudden cardiac death? Your odds for what? For rain during drought?

 

[MedicineZ0Z]

How do you improve your odds by giving a QT-prolonging drug in a disease that regularly causes various cardiac injuries, up to sudden cardiac death? Your odds for what? For rain during drought?

Literally half our meds are "qt prolonging." We routinely give this med out for malaria prophylaxis to folks going to Africa, put them on it for 3 whole months, and no one bats an eye.
And it's not like this disease is causing torsades. It's ultimately a rare arrhythmia that gets so many people worked up.

 

[deleted171991]

Literally half our meds are "qt prolonging." We routinely give this med out for malaria prophylaxis to folks going to Africa, put them on it for 3 whole months, and no one bats an eye.
And it's not like this disease is causing torsades. It's ultimately a rare arrhythmia that gets so many people worked up.

I doubt that anybody with acute myocarditis goes to Africa.

In a Chinese Covid-19 study (below), about 28% of their patients had myocarditis, and 6% had VT/VF (17% in the elevated troponin group).

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

This case series study evaluates the association of underlying cardiovascular disease and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19).

jamanetwork.com

There is also a lot of anecdotal unexplained sudden cardiac death in these patients. I would not be cavalier about QT-prolonging drugs in this population. And I'm the kind of guy who gives haldol/droperidol without even blinking.

And while I understand that HCQ may also interfere with the viral effect on Oxy-Hgb (beyond the "immunomodulatory" wishful effect), which could be a major pathophysiologic mechanism that explains how patients seem to have a significant right-shift in the dissociation curve, it still doesn't convince me yet that the benefits exceed the risks.

 

[deleted171991]

AAAS

blogs.sciencemag.org

Hydroxychloroquine and azithromycin versus COVID-19: Grift, conspiracy theories, and another bad study by Didier Raoult

On Friday, Prof. Didier Raoult posted another study of azithromycin and hydroxychloroquine used against COVID-19. It is a single arm observational study of patients with mostly mild (or even asymptoma

sciencebasedmedicine.org

 

[SurfingDoctor]

The point is to improve your odds, reduce duration and severity of symptoms etc. We have very few definitive anti viral cures.

The biggest mistake with these things is starting it once the patient is in the hospital. It needs to be done the second the pre-test probability is high and no later than when the test is positive. Even for healthy outpatients. Saving it for when they're tubed is just silly. The virus is the least of your worries at that point.

So put it in the water?

As an aside, it’s impressive that you think healthy people are going to take medicines from something they aren’t showing signs or symptoms of. Do you even take care of patients? There are millions of people who are non-compliant with medications even when the know they have diseases (75% of all people on medications last time I checked). Thus that brings me back to my original point. You gonna to put it in the water, like fluoride?

 

[MedicineZ0Z]

I doubt that anybody with acute myocarditis goes to Africa.

In a Chinese Covid-19 study (below), about 28% of their patients had myocarditis, and 6% had VT/VF (17% in the elevated troponin group).

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

This case series study evaluates the association of underlying cardiovascular disease and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19).

jamanetwork.com

There is also a lot of anecdotal unexplained sudden cardiac death in these patients. I would not be cavalier about QT-prolonging drugs in this population. And I'm the kind of guy who gives haldol/droperidol without even blinking.

And while I understand that HCQ may also interfere with the viral effect on Oxy-Hgb (beyond the "immunomodulatory" wishful effect), which could be a major pathophysiologic mechanism that explains how patients seem to have a significant right-shift in the dissociation curve, it still doesn't convince me yet that the benefits exceed the risks.

What does myocarditis have to do with a drug that is mildly QT prolonging? It blocks the hERG K+ channels. Not sure how a viral myocarditis is going to lead to torsades ?? Again, it's a rare rhythm. We see it in patients on multiple Psych meds (still uncommon) or methadone etc.

And I know we don't have amazing data yet. But we have more than just one trial and overall it looks quite promising. More importantly, none of the trials have even looked at patients who started it very early in their disease course. The anecdotal information is strongly supportive of starting it ASAP for maximum efficacy with not amazing results if started late. You also need to use it with zinc.

So put it in the water?

As an aside, it’s impressive that you think healthy people are going to take medicines from something they aren’t showing signs or symptoms of. Do you even take care of patients? There are millions of people who are non-compliant with medications even when the know they have diseases (75% of all people on medications last time I checked). Thus that brings me back to my original point. You gonna to put it in the water, like fluoride?

wha? It's for actual patients who have it.

I'm not following the logic here btw. We have something with very little risk, which likely does provide some benefit. Poor understanding of the risks aren't a reason to not Rx something. It's more reason to educate yourself on it.

And yes I take care of patients. We write for this medication on a daily basis in our hospital.

 

[SurfingDoctor]

I'm not following the logic here btw. We have something with very little risk, which likely does provide some benefit. Poor understanding of the risks aren't a reason to not Rx something. It's more reason to educate yourself on it.

And yes I take care of patients. We write for this medication on a daily basis in our hospital.

Hold up, didn’t you just say the “biggest mistake” is prescribing it once you get to the hospital?

The biggest mistake with these things is starting it once the patient is in the hospital.

Anywho, this has been fun. Good luck.

 

[MedicineZ0Z]

Hold up, didn’t you just say the “biggest mistake” is prescribing it once you get to the hospital?



Anywho, this has been fun. Good luck.

Waiting to start it until then. Cmon dude.

 

[deleted171991]

What does myocarditis have to do with a drug that is mildly QT prolonging? It blocks the hERG K+ channels. Not sure how a viral myocarditis is going to lead to torsades ?? Again, it's a rare rhythm. We see it in patients on multiple Psych meds (still uncommon) or methadone etc.

And I know we don't have amazing data yet. But we have more than just one trial and overall it looks quite promising. More importantly, none of the trials have even looked at patients who started it very early in their disease course. The anecdotal information is strongly supportive of starting it ASAP for maximum efficacy with not amazing results if started late. You also need to use it with zinc.


wha? It's for actual patients who have it.

I'm not following the logic here btw. We have something with very little risk, which likely does provide some benefit. Poor understanding of the risks aren't a reason to not Rx something. It's more reason to educate yourself on it.

And yes I take care of patients. We write for this medication on a daily basis in our hospital.

Ventricular Arrhythmia Risk Due to Hydroxychloroquine-Azithromycin Treatment For COVID-19 - American College of Cardiology

www.acc.org

Life Threatening Severe QTc Prolongation in Patient with Systemic Lupus Erythematosus due to Hydroxychloroquine

We present a case of a syncopal episode resulting from significant QT interval prolongation in a patient on hydroxychloroquine for the treatment of systemic lupus erythematosus and end stage renal disease. The patient had been treated with hydroxychloroquine ...

www.ncbi.nlm.nih.gov

And this is from the FDA:

https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/009768s037s045s047lbl.pdf

PLAQUENIL prolongs the QT interval. Ventricular arrhythmias and torsades de pointes have been reported in patients taking PLAQUENIL (see OVERDOSAGE). Therefore, PLAQUENIL should not be administered with other drugs that have the potential to prolong the QT interval (see DRUG INTERACTIONS)

And to answer your question: YES, myocarditis is well-documented to cause all kinds of arrhythmias, including ventricular ones. It's basic pathophysiology, with all due respect. Almost 17% of Covid-19 patients with elevated troponins had VT/VF in one Wuhan study. That's 1 in 6.

 

[CCM-MD]

Seeing a lot of anecdotes of leaving patients hypoxemic and they "seem to be doing fine"

(i am not advocating this)

 

[deleted171991]

View attachment 300813

View attachment 300814

Seeing a lot of anecdotes of leaving patients hypoxemic and they "seem to be doing fine"

(i am not advocating this)

Apparently the OxyHgb dissociation curve is shifted much to the right, because it's "poisoned" by the virus. That's one of the hypotheses for using HCQ, which supposedly blocks this in vitro. Hence OxyHgb can offload much more O2 in the periphery, despite the O2 sat.

I'm really hoping to see more of this:

Convalescent Plasma to Treat COVID-19

In this issue of JAMA, Shen et al report findings from a preliminary study of 5 severely ill patients with coronavirus disease 2019 (COVID-19) who were treated in the Shenzhen Third People's Hospital, China, using plasma from recovered individuals.1 All patients had severe respiratory failure and...

jamanetwork.com

The first US coronavirus patients are being treated with convalescent plasma therapy. Will it work? Not even the doctors know

Convalescent plasma therapy has a mixed history of success, but doctors are willing to try amid efforts against the pandemic.

www.usatoday.com

 

[MedicineZ0Z]

Ventricular Arrhythmia Risk Due to Hydroxychloroquine-Azithromycin Treatment For COVID-19 - American College of Cardiology

www.acc.org

Life Threatening Severe QTc Prolongation in Patient with Systemic Lupus Erythematosus due to Hydroxychloroquine

We present a case of a syncopal episode resulting from significant QT interval prolongation in a patient on hydroxychloroquine for the treatment of systemic lupus erythematosus and end stage renal disease. The patient had been treated with hydroxychloroquine ...

www.ncbi.nlm.nih.gov

And this is from the FDA:

https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/009768s037s045s047lbl.pdf

And to answer your question: YES, myocarditis is well-documented to cause all kinds of arrhythmias, including ventricular ones. It's basic pathophysiology, with all due respect. Almost 17% of Covid-19 patients with elevated troponins had VT/VF in one Wuhan study. That's 1 in 6.

Your post literally puts "overdosage" beside it lol. Of course there is dose dependent QT prolongation. If I took a lot of methadone, there's a decent chance I'd go into torsades. Does that mean we should not use it specifically for that reason? No, we use appropriate doses.

And I'm not sure how you're saying myocarditis leads to torsades. It can lead to (usually) monomorphic or polymorphic vtach. Pathophysiologically, it makes zero sense for it to specifically cause torsades.

Hydroxychloroquine rated ‘most effective therapy’ by doctors for coronavirus: Global survey

An international poll of more than 6,000 doctors released Thursday found that the antimalarial drug hydroxychloroquine was the most highly rated treatment for the novel coronavirus.

www.washingtontimes.com

 

[VA Hopeful Dr]

Your post literally puts "overdosage" beside it lol. Of course there is dose dependent QT prolongation. If I took a lot of methadone, there's a decent chance I'd go into torsades. Does that mean we should not use it specifically for that reason? No, we use appropriate doses.

And I'm not sure how you're saying myocarditis leads to torsades. It can lead to (usually) monomorphic or polymorphic vtach. Pathophysiologically, it makes zero sense for it to specifically cause torsades.

Hydroxychloroquine rated ‘most effective therapy’ by doctors for coronavirus: Global survey

An international poll of more than 6,000 doctors released Thursday found that the antimalarial drug hydroxychloroquine was the most highly rated treatment for the novel coronavirus.

www.washingtontimes.com

OK so first, yes we absolutely shouldn't be using methadone. I can think of very very few physicians who would have any problem with taking it off the market completely (especially now that Suboxone is a thing). It is exceedingly dangerous to use as an analgesic compared to other opioids (with no evidence of greater analgesia) and at present unnecessary to use as treatment for OUD thanks to the aforementioned Suboxone.

Second, did you really just quote the Washington Times article about a poll of doctors on f-ing SERMO about something clinical?

Third, the results aren't exactly impressive even from that garbage of a source:

The survey conducted by Sermo, a global health care polling company, of 6,227 physicians in 30 countries found that 37% of those treating COVID-19 patients rated hydroxychloroquine as the “most effective therapy” from a list of 15 options.

So just over 1/3rd of the doctors thought it was the most effective therapy. That means 63% didn't think it was. Or to put it another way, the majority of those polled didn't think it was the most effective.

 

[MedicineZ0Z]

OK so first, yes we absolutely shouldn't be using methadone. I can think of very very few physicians who would have any problem with taking it off the market completely (especially now that Suboxone is a thing). It is exceedingly dangerous to use as an analgesic compared to other opioids (with no evidence of greater analgesia) and at present unnecessary to use as treatment for OUD thanks to the aforementioned Suboxone.

Second, did you really just quote the Washington Times article about a poll of doctors on f-ing SERMO about something clinical?

Third, the results aren't exactly impressive even from that garbage of a source:

The survey conducted by Sermo, a global health care polling company, of 6,227 physicians in 30 countries found that 37% of those treating COVID-19 patients rated hydroxychloroquine as the “most effective therapy” from a list of 15 options.

So just over 1/3rd of the doctors thought it was the most effective therapy. That means 63% didn't think it was. Or to put it another way, the majority of those polled didn't think it was the most effective.

It's easy to try and discredit things because you want 20 large RCTs before trying a (very low risk) intervention. All we have are 2 small trials and anecdotal data.
But nonetheless, anyone who thinks this drug has real side effects (and considers that their barrier to using it) either doesn't practice medicine or is grossly misinformed about cardiac toxicity.

 

[VA Hopeful Dr]

It's easy to try and discredit things because you want 20 large RCTs before trying a (very low risk) intervention. All we have are 2 small trials and anecdotal data.
But nonetheless, anyone who thinks this drug has real side effects (and considers that their barrier to using it) either doesn't practice medicine or is grossly misinformed about cardiac toxicity.

I'm not trying to discredit that garbage article because I'm demanding large RCTs. I'm discrediting it because its utter garbage. Its a freaking anonymous survey in a pretty ****ty part of the internet that doesn't even show a majority of the respondents saying that the treatment is the best option.

I don't actually have a strong opinion on plaquenil at the moment, but I do have strong opinions on junk science which that article you posted is full of.

I may have my concerns about studies out of China or that one specific French doctor, but at least those aren't trying to prove we should use a specific treatment based on a survey.

 

[Colorado outliers]

Anecdotally it seems like we have two categories of treatments.

1. Hydroxychloroquine +/- azithromycin.

2. Xeljanz/Anakinra/Tocilizumab.

The first category is treating the virus and superimposed bacteria. The second category is treating the cytokine storm and quite useful for when the patient is in ARDS. I think it's a reasonable school of thought that the first category should be used early (outpatients and early inpatient) and the second category should be the primary treatment modality for those who are tubed. Treating the virus once tubed probably isn't going to induce a dramatic turnaround, it needs to be stopped early on.

Thoughts??

(and aware we're still waiting on remdesivir)

We have been HCQ basically for anyone who is intubated...5 day course, not sure if it's done anything.
Not using azithro with HCQ.
Can't get Remdesivir right now as we don't have an active clinical trial here and compassionate use has dried up.

Have given Toci to a few 'hyperinflammatory' patients - sky-high CRP, Ferritin, D-dimer etc. Anecdotally one of them seemed to respond w/ improved vent settings. Usual dosing for CRS is q8 hrs x 3 but we've been giving one dose then reevaluating at 24 hrs to see if there is benefit before 'wasting' more of it.

We will be part of the plasma trial - have not given it to anyone yet.

Has anyone here used Kaletra w/ Ribavirin? Seems like that combo was being used in China, but no one here seems to think it will work.

 

[SurfingDoctor]

View attachment 300813

View attachment 300814

Seeing a lot of anecdotes of leaving patients hypoxemic and they "seem to be doing fine"

(i am not advocating this)

I mean, gradual hypoxemia can be tolerated relatively well. We leave kids with right to left mixing lesions in the 70s (sometimes in the high 60s when you gotta lower those expectations) for months. If you keep your hemoglobin high enough, it’s quite tolerable.

40s though... . At that saturation, that seems dicey. It probably could be tolerated for a couple of days in overall healthy people without significant cardiac disease. But why take that risk?

 

[CCM-MD]

I mean, gradual hypoxemia can be tolerated relatively well. We leave kids with right to left mixing lesions in the 70s (sometimes in the high 60s when you gotta lower those expectations) for months. If you keep your hemoglobin high enough, it’s quite tolerable.

40s though... . At that saturation, that seems dicey. It probably could be tolerated for a couple of days in overall healthy people without significant cardiac disease. But why take that risk?

It is making me question whether I should have put a couple of people on the vent for severe hypoxemia without respiratory distress this past week.

 

[SurfingDoctor]

It is making me question the couple I put on the vent this past week for severe hypoxemia without respiratory distress.

Why? The ventilator isn’t going to kill them, the disease will. I mean, it’s probably okay to watch people in the 80s (maybe even 70s... maybe) temporarily if they have a static trajectory, but for that patient in the 40s, waiting till they are less than that just seems dangerous.

This seems like the antithesis of the Italian experience of intubating early. To me, if seems less of an early versus late and more of a question of optimal safety.