June 11, 2020

Background: In end-stage renal disease (ESRD) patients on hemodialysis (HD), infection is the second most common cause of mortality after cardiovascular disease (Sarnik 2000). Because of the systemic inflammation and increased capillary permeability, septic patients are at significant risk for fluid imbalances and frequently require large volumes of crystalloids. The Surviving Sepsis Campaign guidelines provide a strong recommendation with low quality of evidence for administering a 30mL/kg fluid bolus within 3 hours of recognition of sepsis-induced hypoperfusion (Rhodes 2016). Further fluid administration should be guided by hemodynamic assessment (bedside echocardiography, passive leg-raise, etc.). In the general population, this early administration of fluids to patients with hypotension or sepsis-induced hypoperfusion has been associated with improved outcomes. However, there is significant confusion regarding the effects of a large 30mL/kg bolus on ESRD patients due to a lack of studies. While these patients may appear, volume overloaded on physical exam, they may be intravascularly volume deplete. Physicians may be hesitant to administer a large fluid bolus in ESRD patients because of the risk of precipitating cardiogenic shock, pulmonary edema, and respiratory failure. In fact, multiple studies show that patients who have ESRD are less likely to receive the full 30mL/kg fluid bolus compared to non-ESRD patients (Lowe 2018, Truong 2019, Dagher 2015). Furthermore, some studies show equivalent outcomes between ESRD patients who receive the full bolus and those who do not. We will review two studies that examined this topic.

June 8, 2020

Background: Despite the initial excitement around the use of chloroquine (CQ) and hydroxychloroquine (HCQ), there is mounting evidence that neither drug is effective in COVID-19 treatment. Laboratory studies have shown antiviral and immunomodulatory properties in vitro but these have not held up in clinical application. However, one potential area of use that needs more investigation is the use of HCQ for post-exposure prophylaxis (PEP). As the pandemic continues, PEP becomes an increasingly important topic in stopping repeat surges of the disease. To date, there is no high-quality evidence on prophylactic HCQ after exposure.

June 6, 2020

Background: Convalescent plasma therapy is not a new or novel therapeutic option.  It involves taking the plasma from patients who have recovered from an illness and using it to treat patients who currently have the same illness. This approach has been evaluated in the treatment of SARS, MERS, and ebola but, none of the studies in these disease showed definitive results.  Thus far, the amount of evidence on convalescent plasma therapy in COVID-19 is also limited.  There was a case series of 5 patients [2] and a systematic review of 5 trials with 27 patients [3]. Neither study was earth-shattering. However, both showed  improved weaning from mechanical ventilation and no adverse events in the convalescent plasma group.  With a total of 32 patients, we should not put any weight in either of these trials.  We now have our first randomized clinical trial on convalescent plasma therapy.

June 2, 2020

Background: We have covered the two previous RCTs on remdesivir on REBEL EM (RCT #1 and RCT #2). In the first trial by Wang et al [2], there was no statically significant improvement in clinical outcomes, but, there were trends toward shorter duration of illness. In the ACTT-1 preliminary report [3], despite all the methodological issues, there was a 4 day decrease in clinical improvement (although not in patients requiring HFNC/NIV/IMV/ECMO).  Neither trial was perfect, however in the middle of pandemic, a several day decrease in recovery time may be beneficial in reducing hospital crowding if the difference holds true in subsequent studies and if the correct target population is known.  We now have our 3rd RCT on remdesivir [1], just published in the NEJM comparing 5 days vs 10 days of remdesivir in patients with severe COVID-19.

May 31, 2020

I am fortunate to work in a hospital system that is very forward thinking.  We have a phenomenal relationship with our intensivists, and I have been fortunate enough to have several discussions with them about how we are managing COVID-19 in our ICUs.  For full transparency, I don’t work up in the ICU, but had the opportunity to discuss what we are doing in our ICUs with one of our intensivists (ECMO, steroids, Remdesivir, etc...).  We are doing something different in San Antonio that I thought was worth discussing on this podcast that may be a feasible option for some institutions and some patients, but not all. If there is one thing this disease has taught me, that is one size does not fit all.