Background: Though it’s been stated numerous times on this blog, it bears repeating: the pillars of sepsis care remain early identification of sepsis, early appropriate empiric antibiotics, source control, and supportive care. The focus should be on getting the basics right but, it is important to evaluate whether other adjunctive therapies can help decrease mortality in a common and frequently fatal condition. Ascorbic acid and thiamine deficiency have been described in patients with sepsis and are thought to be due to reduced intake and increased metabolic demands. Corticosteroids have had mixed results but seem to improve shock reversal in patients with septic shock based on best available evidence (Link is HERE). There have been a slew of RCTs evaluating this metabolic cocktail (vitamin C, thiamine, & corticosteroids) in recent months. Though biologically plausible, this treatment approach has not been shown to improve patient-oriented outcomes....Read More
Background: There are three randomized clinical trials now published on remdesivir in the treatment of COVID-19 pneumonia (RCT 1, RCT 2, & RCT 3). The 1st trial, performed in China, was terminated early due the lack of patients to enroll and, as a result, did not give strong recommendations. The 2nd trial (ACTT-1) showed a statistically significant 4-day reduction in time to recovery. However, it was also terminated early due to an interim analysis, which meant we do not have outcomes on 30% of patients enrolled. Finally, the 3rd RCT compared a 5-day to a 10-day course of remdesivir and showed no difference in outcomes with more acute kidney injury in the 10-day course. All of these trials have significant issues leaving clinicians unsure of the efficacy of the drug, when to administer it, how long to give it for and, in which patient group it should be given. We now have our 4th RCT of remdesivir evaluating the efficacy and adverse events of remdesivir administered for 5- or 10-days vs standard care in hospitalized patients with moderate COVID-19....Read More
Background: Over the past few years, corticosteroids have gained traction in the treatment of patients with ARDS and septic shock. Trials such as APROCCHSS and ADRENAL have shown that the use of corticosteroids is associated with more rapid resolution of shock, weaning from mechanical ventilation in septic shock, and, potentially lower mortality. The RECOVERY trial, the largest RCT to date on the use of corticosteroids in COVID-19, showed treatment with dexamethasone (6mg/d for 10 days) had an absolute mortality reduction of 11% in patients receiving mechanical ventilation (IMV) (NNT = 9), 3.5% decreased mortality in patients requiring O2 but not IMV (NNT = 29) and an overall mortality reduction 3% (NNT = 3) compared to usual care alone. However, there was a signal toward harm (not statistically significant) in patients not receiving respiratory support.
In the September 2020 issue of JAMA, there were 3 RCTs (REMAP-CAP, CoDEX, & CAPE COVID) assessing corticosteroid therapy in critically ill patients with COVID-19, as well as a prospective meta-analysis. All 3 RCTs halted enrollment in June 2020 after the RECOVERY trial press release. The prospective meta-analysis from the WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) working group pooled data from 7 trials (RECOVERY, REMAP-CAP, CoDEX, CAPE COVID, and 3 additional trials) with roughly 1700 patients.
In this post we will review the REMAP-CAP, CoDEX, and CAPE COVID trials, as well as the prospective meta-analysis....Read More
Case Presentation: A 4-year-old previously healthy Hispanic female presented to the ED with a diffuse rash and facial swelling, concerning for an apparent allergic reaction. She was rushed into the treatment area for evaluation of possible anaphylaxis and respiratory assessment. She was tachycardic with a heart rate in the 130s, tachypneic, and borderline hypotensive for her age. Initial exam was negative for wheezing or stridor, but she had edema to the face and neck with a red raised rash covering her face. Epinephrine, Benadryl, and Solumedrol were ordered STAT given concern for airway compromise secondary to a severe anaphylactic reaction. ...Read More
The Coronaviridae family and its genera coronaviruses have been implicated as having neurotropic and neuroinvasive capabilities in human hosts (Bohmwald 2018). They have been associated with the development of neuropsychiatric symptoms, seizure activity, encephalomyelitis, acute flaccid paralysis, cerebral venous sinus thrombosis, Guillain-Barré syndrome, as well as cerebrovascular disease (Bohmwald 2018, St Jean 2004).
Recently, there has been a growing body of evidence supporting the association of SARS-CoV2 with neurological abnormalities. A systematic review looking at the incidence of secondary neurological disease in patients diagnosed with SARS-CoV2 found rates to vary from 6-36.4% (Herman 2020).
At the time of this submission, there have been ten reports of acute transverse myelitis (ATM) attributed to SARS-CoV2, and others are currently being submitted or are in pre-print at this time (See infographic below).
ATM has a varied presentation and is associated with significant morbidity and mortality that necessitates increased awareness and vigilance on the part of the clinician. This has become especially important in light of a possible causal link of ATM to SARS-CoV2 with emerging cases during the COVID-19 pandemic.
Here, we review the salient features of infectious ATM (both para-infectious and post-infectious) to increase recognition of this disease entity....Read More