The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic.  The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target.

REBEL COVID-19

will serve as a summary of what is currently known, how to screen, when to test, and how to prevent spread, and any new data/information on COVID-19.

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.

May 30, 2020

Background: One of the hot topics in COVID-19 care is the mortality rate associated with invasive mechanical ventilation (IMV). There have been early reports of IMV having mortality rates ranging from 50 to 90%.  These high rates are concerning but, context is important; many of the reports emerged from areas with large surges where hospital systems were overwhelmed. Additional data looking at outcomes of critical patients is important particularly within systems that were able to maintain baseline critical care provisions despite surges.

May 26, 2020

Background: The saga of Remdesivir for treatment of COVID-19 continues. We previously covered two studies of this drug on REBEL EM (Link is HERE & Link is HERE). One trial (≈200pts) showed no difference in the primary outcome of median time to clinical improvement and the second trial was a compassionate release study which gave us no real clinical information due to its design. A third study was mentioned in the first post from the NIAID, but we didn’t really review it, as much as mention it, as no data was made available.  It was a little teaser from the National Institute of Allergy and Infectious Diseases (NIAID). Despite these facts the FDA approved remdesivir for use and we have had no robust data supporting its use except for the tease of the NIAID study.  Part 1 of the NIAID trial was just published in the NEJM as a preliminary report and we will review here on this post: Remdesivir ACTT-1.

May 24, 2020

This publication has now been retracted by Lancet (June 4, 2020) Background: There is no conclusive evidence that chloroquine, or its derivative hydroxychloroquine, with or without a second-generation macrolide is effective in COVID-19 treatment or prophylaxis. Laboratory studies have shown antiviral and immunomodulatory properties in vitro. The small retrospective observational trials thus far have had mixed results in efficacy.  However, these medications are well known to have cardiovascular adverse effects via QT interval prolongation leading to ventricular arrhythmias. Despite the potential harms and the absence of convincing data to support treatment with these drugs, they are widely prescribed to COVID-19 patients.
0