Fluidity and Futility of COVID 19 - Randy C. Roth, MD Chief Medical Officer - AWS
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Fluidity and Futility of COVID 19 Randy C. Roth, MD Chief Medical Officer
Therapeutic Management of Covid 19 as of 5/21
• Early in clinical course, morbidity associated with
Sars Cov 2 replication
• Late in disease process, morbidity driven by
dysregulated immune/ inflammatory response.
6/5/2021 2
Patients with Moderate Covid 19, NOT Hospitalized
• Low risk, supportive care
• High risk of disease progression, outpatient infusion
with :
• Bamlanivimab / etesevimab Or Casirivimab /
imdevimab
• (Regeneron)- possibly more effective vs variant
strains
• Better outcomes ( decrease hospitalizations) if given
early in disease course. 6/5/2021 3
Clinical Data
• Blaze trials - endpoints being hospitalization or
death Bamlanivimab / etesevimab
• 11 / 518 events in treatment group
• 36 / 517 events in placebo group
• With significant RRR 70 %
6/5/2021 4
Casivivimab/ Indevimab trials
• Same endpoints
• 18 / 1,355 events treatment group
• 62 / 1,354 events placebo group
• Significant RRR of 77 %
6/5/2021 5Patients Requiring Hospitalization but no Supplemental
Oxygen Needs
• No data to support use of steroids (Recovery)
• Insufficient data to recommend for or against
use of remdesivir (ACCT_1)
6/5/2021 6Patients Requiring Hospitalization with Hypoxia, but not High Flow Supplemental Oxygen • Remdesivir/ Dexa ACCT- 1 trial • Improved time to recovery and decreased to need for higher oxygen requirements • No survival benefit • Dexa 6 mg IV QD for 10 days • Baricitinib / Remdesivir when Dexa is contraindicated (ACCT 2 ) • Improved median time to recovery and progression to MV 6/5/2021 7
Patients on High Flow Oxygen / NIV
• Dexa alone or in combination with Remdesivir
• In small subset of patients with rapidly
increasing oxygen needs and high inflammatory
markers, add Tocilzumab to either option .
• Both Remap-Cap and Recovery trials showed
decrease mortality in this subset patients.
6/5/2021 8Patients with Covid 19 on MV / ECMO • Dexa • No role for remdesivir if present with need for MV early • Tocilzumab / dexa showed decrease mortality Recovery/REMAP • For patients who started on monotherapy with remdesivir and progressed to MV, continue dexa / remdesivir. 6/5/2021 9
More Covid Fun Facts
• NAAT URT swab remains test of choice
• No real role for antigen/antibody testing, past
blood drive issue recently
• No role for pre or post exposure prophylaxis
6/5/2021 10More Covid Fun Facts
• No role for addition of supplements
• Early anticoagulation with varying doses is
advocated in these hospitalized patients
6/5/2021 11Futility of Covid 19
Futility of Covid
• In May of 2020, our Ethics Committee
recommended a Futility of care policy to our
Board Of Trustees.
6/5/2021 13Futility Policy
6/5/2021 14Futility Policy
6/5/2021 15Futility Policy
6/5/2021 16Long Term Impact of COVID 19
Long Term Impact of COVID 19
• Recent study involving 47,000 covid 19 patients
hospitalized in England, discharged before
September 2020, and followed versus similar
control group with non covid discharges.
• Covid 19 patients had:
• 4 times higher rate of readmission
• 8 times increased in mortality vs control
group. 6/5/2021 18Long Term Impact of COVID 19
• Major new diagnosis in this period revealed:
• 27 times increase in pulmonary morbidity
• 3 times more likely in cardiovascular disease
• 2 times more likely to have new onset DM.
• Overall, covid 19 survivors had almost 60 %
increase in risk of death over first 6 months, this
data consistent with VA trial following 70,000 va
patients with confirmed covid 19.
6/5/2021 19Long-Term Pulmonary Impact
• Hard to predict who will develop post covid
pulmonary dysfunction
• PFTs reveal restrictive pattern with decrease DL
CO
• Early signs of pulmonary Hypertension
• Some early data on use of steroids for up to 6
months post discharge
6/5/2021 20Long-Term Pulmonary Impact
• Lancet,1/21 390 of the 516 patients were
followed with PFT, HRCT, and Lower extremity
US.
• At 6 months out, 56% had reduced diffusion
capacity and over 30 % still had abnormal HRCT
of chest.
• JB Case Study (CTs to follow)
6/5/2021 21JB Case Study
6/5/2021 22JB Case Study
6/5/2021 23JB Case Study
6/5/2021 24Mental health
• With combination of patient isolation, and covid
stress, large increase in post discharge mental
wellness
• Approximately 17 % have new anxiety requiring
visit to health care provider, 14% with mood
disorder, and 8 % substantial progression of
dementia.
6/5/2021 25GW Case Presentation
GW Case
• GW is a 43 yo AA male, who was our 5th covid
patient.
• Admitted on March 27th, 2020, with 2 other
family members with Respiratory failure 2 nd to
Covid.
• He progressed to MV,ESRD and was our first
trached and pegged patient.
6/5/2021 27GW Case • His situation made worse by the fact that 2 of his 3 siblings died from covid. • His POA is the other younger brother. • He has survived as a full code over the last 15 months, on long term HD, in vegetative state. • He has coded 2 times, lost 100 pounds, and has spent 389 of the last 410 days in one of our hospitals. 6/5/2021 28
GW Case • POA refusing transfer to Georgia facility that can care for his HD needs. • He has 2 stage 3 sacral decubitus, and considering diverting ostomy to help possible healing. • Has been discharged home with family with longest discharge lasting 11 days before family breakdown . 6/5/2021 29
Case GW Solution
• Any Input?
6/5/2021 30You can also read
