Dyssynchrony Mechanical Ventilation

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Protamine dosing for neutralizing heparin and LMWH

Management of post-acute covid-19 in primary care

 

BMJ talk medicine · What Do We Know About Long Covid

Delta Rising

The Delta variant is gaining in many countries in Europe and the US https://t.co/QwXCwaCq6c @AnnaSophieGross @labboudles @jburnmurdoch @FT
And in Israel, the most fully vaccinated country, there have been 2 new school Delta outbreakshttps://t.co/rBmPsuntfv @TimesofIsrael pic.twitter.com/UVx27jqpDf

— Eric Topol (@EricTopol) June 20, 2021

We need to build a Delta immunity wall through more vaccination: 47% Americans haven't even had 1 dose
—There has not been any counter-offensive to the anti-vaxx movement
—No statement by FDA about full licensure timeline (review should be done by now) and no coverage by media pic.twitter.com/c4aL3mrrJE

— Eric Topol (@EricTopol) June 19, 2021

Bradycardia in SarsCov2 Infection

Bradycardia i.e. Mobitz 1, Mobitz 2 or complete heart block ,junctional rhythm, sinus bradycardia and/or pauses can be an initial presentation COVID-19. It appears this is actually a marker for poor prognosis. Multiple series have been published on this. Bradycardia is a frequent clinical feature of COVID-19. Actually most patients do not mount a significant tachycardia, compared to sepsis.This may also imply that patient with COVID 19 can have a PEA arrest with no other causes ( hypoxemia, etc)

Typically  heart rates are well below 100-120 bpm. Mechanistic explanation is likely due to direct pathogenic effects on the sinoatrial node and effects of inflammatory cytokines are among the proposed mechanisms. Despite management of bradycardia with temporary or permanent leadless pacemakers, there is a high rate of short‐term morbidity and death due to complications of COVID‐19. 

Interleukin 6 (IL-6) is the cytokine reported to exhibit the strongest correlation with depressed heart rate variability, which in turn may predict relative bradycardia.

I managed last 2 days a patient with significant sinus bradycardia heart rate 30s to 40s, intubated on mechanical ventilation for COVID-19 pneumonia, but on norepinephrine (not hypothermic). She responded well to atropine and heart rate would go up to 75 bpm. However little effect was obtained from switching from norepinephrine to dopamine. 

Below I linked several articles that refer to a very poor prognosis for patients that have early bradycardia and/or persistent bradycardia in the intensive care unit during SARS CoV-2 management. I also attached an article that gives an overview of bradycardia management in general. This is from the European Society of Cardiology published in their 2015 guidelines.

Be aware that Aminophyllin or theophylline, particularly in elderly patients can be used as a temporary measure to manage brady- arrhythmias, provided there is no ischemia and can even placed on an oral regimen of theophylline . Temporary pacemakers in general should be discouraged. They have a significant complication rate and if patient meets pacemaker criteria, he or she should be managed like a STEMI and brought urgently to the EP lab for emergent permanent pacemaker implantation.

Bradycardia in Patients with COVID -19: A Calm Before the Storm 

Reference of the above figures

Hemodynamic Monitoring in the ICU

 

Volume View System   multiple physiologic variables including EVLW ( extra vascular lung water ) 

Argos by Retia Medical   CO monitor 

A global perspective on vasoactive agents in shock

 Excellent article and I have also attached the Webinar discussing protocols

6 Therapies for COVID-19

 

The Game Changer for Tele-ICU (maybe) Here

 

Wake Med in Raleigh, NC only one in 2 sites in the US actively using the technology 

Israeli medical analytics startup Clew Medical announced this week that it received 510(k) clearance and authorization from the US FDA for the use of the Clew-ICU, the company’s artificial intelligence-based ICU solution, to predict hemodynamic (blood flow) instability in adult patients.

The clearance is the FDA’s first for such a device and follows the FDA’s Emergency Use Authorization (EUA) for Clew’s respiratory deterioration model granted in June 2020 for the predictive screening of COVID-19 and other ICU patients.

Founded in 2014, Clew develops real-time AI analytics platforms designed to help providers make better-informed clinical decisions by predicting life-threatening medical complications. Clew’s platform adjusts to cope with patient volume surges, reducing a caregiver’s exposure risk to infected patients, according to the company.

Clew-ICU monitors and categorizes patient risk levels, providing clinicians with physiological insight into a patient’s likelihood of future hemodynamic instability, the company says. The system provides notification of clinical deterioration up to eight hours in advance, enabling early evaluation and subsequent intervention for prompt, proactive patient care.

The system also identifies low-risk patients who are unlikely to deteriorate, thus enabling better ICU resource management and optimization.

Clew-ICU receives patient data from various sources, including Electronic Health Record (EHR) data and medical device data, which is then analyzed in near real-time to present calculated insights and notifications.

“We are proud to have received this landmark FDA clearance and deliver a first-of-its-kind product for the industry, giving healthcare providers the critical data that they need to prevent life-threatening situations,” said Gal Salomon, Clew CEO.

“AI can be a powerful force for change in healthcare, enabling assessment of time-critical patient information and predictive warning of deterioration that could enable better informed clinical decisions and improved outcomes in the ICU,” said Dr. David Bates, Medical Director of Clinical and Quality Analysis in Information Systems at Mass General Brigham healthcare system in Boston and Clew Advisory Board member.

COVID-19: Guidance on Tocilizumab

NIH on tocilizumab: The National Institutes of Health has slightly upgraded tocilizumab as a treatment for COVID-19 in its latest COVID-19 treatment guidelines. Previously, the group recommended against the use of tocilizumab and other anti-interleukin-6 receptor monoclonal antibodies (e.g., sarilumab) outside of clinical trials. Now, citing conflicting evidence, the guideline panel says there are not enough data to recommend for or against the use of tocilizumab or sarilumab to treat COVID-19 in patients who have been admitted to the intensive care unit in the past 24 hours and require mechanical ventilation or high-flow oxygen. Some panel members, citing the REMAP-CAP trial, say that for patients who meet the above criteria and have rapid progression of respiratory failure, they would administer a dose of tocilizumab (8 mg/kg of body weight, up to 800 mg) plus dexamethasone. For patients who don't require ICU care, the panel continues to recommend against these drugs.

NIH COVID-19 Treatment Guidelines update (Free)

The Lancet Public Health article on testing frequency (Free abstract)

NEJM Journal Watch COVID-19 page (Free)

NEJM COVID-19 page (Free)

Not all DOACs are created equily

RCTs     see link for article discussed 

Although phase III clinical trials provide the highest-quality level of evidence it is important to have results from observational real-life cohort studies, as patients in daily clinical practice may substantially differ from those included in RCTs, in terms of comorbidities as very elderly or patients with cancer or advanced chronic and liver disease are usually excluded or under-represented. Furthermore, patients included in RCT are usually strictly monitored and length of follow-up is usually 

Again , a confirmation that the external validity of RCTs is limited and real life follow up data a necessary. All DOACs have been compared to VKA , but not against each other . 

Full-dose blood thinners decreased need for life support and improved outcome in hospitalized COVID-19 patients

 Based on the interim results of more than 1300 moderately ill patients admitted to hospital, findings showed that full doses of blood thinners were not only safe, but superior to the doses normally given to prevent blood clots in hospitalized patients. Moderately ill patients are those not in ICU and who did not receive organ support such as mechanical ventilation at trial enrollment. The trial investigators are now working as fast as possible to make the full results of the study available so clinicians can make informed decisions about treating their COVID-19 patients.

These trial results reported today complement the group’s findings announced in December that routine use of full-dose anti-coagulation when started in the ICU in critically ill COVID-19 patients was not beneficial and appeared to be harmful. 

mRNA vaccines

Stanford Grand Rounds