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Pearls and Best Practices of COVID-19 Inpatient Care - Shared screen with speaker view
Peggy McCreary
Please remember to enter your questions into the chat.
Sharon Hendricks
When do you recommend CTA in patients with elevated d-Dimer?
Bridget Hovendon
This is great - Will there be access to the recorded lecture afterwards? Thanks
Darlene Tad-y
Yes! We will make the recording available to everyone and also will post on the CHA website.
Will there be access to slides?
Darlene Tad-y
Yes - slides will also be posted.
Longfellow, Sam
where will slides be posted
Darlene Tad-y
We will post the slides and the recording on the CHA website under “COVID-19 Resources” and will also share with hospital and medical staff leadership
Amiran Baduashvili
We typically do not use D-dimer alone in that decision. We usually obtain CTA in patients with high oxygen requirement and unimpressive lung imaging that don’t seem to be consistent with the degree of hypoxia. We also tend to scan patients who continue to worsen despite initial treatment. The specificity of D-dimer in the diagnosis of VTE seems to be low as many patients have very high d-dimer without evidence of VTE. High d-dimer in these patients could be due to inflammation and microvascular thrombosis. Bottom line - keep high index of suspicion for VTE as prevalence of VTE is high in patients with severe Covid-19
what is the success rate of Remdesivir at DHMC and UH
Sarah Brown
Are the SOLIDARITY results changing your approach?
Amiran Baduashvili
At UCH, we have not done a randomized trial to see whether it is effective.
David Mohlman
Have you seen any seizure activity associated with remdesivir?
Our anecdotal experience at Denver Health seems to match that in the published studies. Seems to help patients with some (but low) oxygen requirements in preventing progression of disease and mechanical ventilation.
What treatment do recommend for symptomatic outpatients who are maintaining marginal oxygen saturations?
Amiran Baduashvili
Seizures - I have not seen them associated with Remdesivir
Sharon Hendricks
When considering Remdesivir is there any benefit to providing in the ER and discharging home? Our ER has requested to use but based on recommendations for treatment it would seem that it should be limited to inpt. use.
I also have not seen seizures with remdesivir
Amiran Baduashvili
Treatment for symptomatic outpatients - at this moment, the only approved treatment for symptomatic outpatients is monoclonal antibody by Eli Lilly (recently received FDA EUA). Dexamethasone was not studied in outpatients (it was discontinued upon discharge)
David Mohlman
Seizure is listed as adverse effect and I have had once case in a 92 year old after two doses. No other explanation for seizure and no recurrence after stopping remdesivir
Amiran Baduashvili
Remdesivir in ER prior to discharge - we do not use a single dose Remdesivir at UCH
We also do not use Remdesivir for patients seen in ED who are not admitted
Peter Craig
Would really appreciate a recording of this. If there is a way to watch this again, later, please let me know. Much appreciated.
Amiran Baduashvili
Remdesivir was studied in mild to moderate covid, and the results of that study was published in JAMA. That study showed statistical benefit in patients treated with 5-day course but not a clinically meaningful benefit in time to recovery. No mortality benefit. https://jamanetwork.com/journals/jama/fullarticle/2769871
Liz Edelstein
Is the Eli Lilli monoclonal antibody already being distributed/ made available?
Darlene Tad-y
We will post the slides and the recording on the CHA website under “COVID-19 Resources” and will also share with hospital and medical staff leadership
Longfellow, Sam
what are your thoughts on using fenofibrates? have there been any studies?
Darlene Tad-y
CDPHE will be receiving doses from the federal government and will be distributing the doses according to an algorithm that is currently being determined.
Sarah Goodpastor, MD
if in a rural area w limited capacity to admit and managing hypoxic patients at home on O2 with RN home monitoring, do you find it reasonable to use dexa
Christopher Dondlinger
Does our starting elevation change how you classify the severity of the disease?
Amiran Baduashvili
Use of dexa in outpatients with new oxygen requirement - this has not been studied. In the RECOVERY study, patients took dexamethasone for 10 days or until discharge (median of ~7 day duration). That said, I am not sure how many patents were discharged on oxygen on that trial. Therefore, use of dexamethasone with outpatients who require oxygen would be an extrapolation from RECOVERY and the evidence is indirect. I think one can make a reasonable argument to use dex in that setting. Would advise more caution with patients with high risk of complications from steroids, such as brittle diabetes
Sharon Hendricks
We are also in a rural area but have rapidly worked out getting home oxygen availability for order from the ER.
Brittany Blass
Can you please provide the link to where these slides and presentation will be posted?
Amiran Baduashvili
Disease severity definition - studies define severe covid-19 as less than 94% saturation at room air. Most of these studies are done at see level, which is equivalent to roughly 90% on room air here
Amiran Baduashvili
Due to elevation
Christopher Dondlinger
So you are using dexa on patients sating 89-90%, on RA? Or only if you use supplemental O2?
Amiran Baduashvili
Dex in low oxygen requirement 1-2L is up to clinical judgment. If patient has extensive infiltrates on CXR, appear ill, high inflammatory markers and 89% on room air, and only requiring 1-2L on room air, I may consider using dex in that patient. If a patient looks well, has 1L oxygen requirement, unimpressive imaging, and relatively reassuring inflammatory markers, and brittle diabetes, I may defer treatment for that patient.
Amiran Baduashvili
The benefit of dexamethasone is incremental in oxygen requirement - patients requiring mechanical ventilation had most benefit (12% absolute risk reduction in death, number need to treat to save one life = 8). For patients on oxygen requirement, risk reduction was 3%, and NNT was 30. Thus, benefit was still there, but attenuated. For patients who did not require oxygen, they had trend towards worse outcomes (perhaps due to side effects). Thus in those patients with borderline O2 requirement, especially up here in Colorado, we can use clinical judgment and harms/benefits discussion
Christopher Dondlinger
But how often are you admitting someone without an oxygen requirement? What criteria do you use(is this coming in the presentation?)
Gaby Frank
Gaby Frank
ACTT-1 final report
Jessica Lynde
is there a link to register for CME? I was given this zoom link via email.
Amiran Baduashvili
We usually do not admit patients without oxygen requirement unless there is an additional reason to admit (acute renal failure, hyponatremia, etc), or provider has a clinical concern (i.e., patient appears sick, and is immunocompromised).
Gaby Frank
Solidarity trial had many design flaws, definitely not comparable with ACTT and that is why FDA approved even after pre print of SOLIDARity. I will share with group some pointer
what is the additional benefit of checking ferritin in additional to CRP?
Longfellow, Sam
I may have missed it, but what are your thought on fenofibrate? ICU docs down here have been putting nearly all patients on this
Gaby Frank
Solidarity LIMITATIONS:No placebo No double-blinding No standard data monitoring  Variable diagnostic confirmation of infection  No timing of symptoms duration before treatment initiation 
Gaby Frank
Seems patients were required to stay in the hospital for a fixed 10-day course of remdesivirImplementation and study drug distribution with reported delivery failures and disorganizationUnknown baseline physiological severity, supportive care provided, health care capacity status of enrolling sitesMissing data (need to prevent information bias)
Gaby Frank
Gaby Frank
A randomized, double-blind, placebo-controlled study with a systematic collection of clinical and laboratory data, morbidity and mortality outcomes, and a data and safety monitoring committeeACTT-1 demonstrated numerous significant clinical benefits of Remdesivir: 5 days for all (10 vs 15), and 7 days (11 vs 18) shorter time to recovery in the sickest patients (P<0.001)50% faster clinical status improvement8 days less receiving oxygenlower progression to non-invasive ventilationlower progression to invasive mechanical ventilationFewer subsequent days in VM/ ECMO (if present at enrollment)- 17 vs 20  lower overall mortality at day 29 (0.73[0.52-1.03]) Significant overall mortality reduction at day 15 (0.55[0.36-0.83])- (6.7% vs 11.9%)significant mortality reduction in patients who were requiring oxygen at day 15 (0.28[0.12-0.66]) and at day 29 (0.30[0.14-0.64])all of the above mortality reduction estimates were detected even though the trial was not powered for mortality.
John Fox
What is the risk of secondary bacterial infection in COVID-19 patients?
Valerie - CHA Education
If you would like a certificate of attendance for this session, please contact me at Valerie.siebertthomas@cha.com.
Amiran Baduashvili
Ferritin in addition to CRP question - really unclear if there is a benefit of checking ferritin. Based on our internal data, CRP may be a better predictor, among LDH/Ferritin/CRP. I personally only use CRP and check it every other day
Gaby Frank
per Cochrane review
Darlene Tad-y
Our session this Friday, Nov 20 at noon will be with our critical care colleagues and will cover intensive care of COVID-19 patients.
Amiran Baduashvili
Risk of secondary bacterial infections - culture confirmed bacterial infections seem to be quite low in our patients. That said, as some of the patients worsen and require high oxygen (in ICU or step-down), some receive empiric antibiotics
Gaby Frank
Sorry, per Cochrane review Solidarity is flagged in several domains as high risk of bias trial , despite its large size... So in summary it doesn't change the assessments or recommendations of remdesivir use
Peter Craig
From what I understand, many autopsy results show diffuse pulmonary in-situ thrombosis. Are there patients being admitted to the hospital who you are NOT anticoagulation (of course, only considering those without a direct contraindication0. There is much talk of DVT’s, but with the in-situ pulmonary thrombosis, isn’t w/u for DVT’s relatively irrelevant in anticoagulation decisions, or am I misunderstanding?
Gaby Frank
ACTIV-4 trial is studying anti-thrombotics
Darlene Tad-y
Slides and recording (including chat transcript) will be posted here https://cha.com/covid-19/
Amiran Baduashvili
We generally use high prophylactic doses rather than full dose anticoagulation in patients without confirmed VTE
Amiran Baduashvili
For example, in an ICU patient without confirmed VTE and with wt>100kg, we use Enoxaparin 40mg BID rather than daily
Amiran Baduashvili
(And high d-dimer)
Peter Craig
Anecdotal evidence: Enoxaparin not seeming to be reliably effective, Heparin seeming to work much better. Just anecdotal…but seems noticeable.
Sharon Hendricks
We are seeing a lot of new onset A-fib
Gaby Frank
Gaby Frank
Modified IMPROVE-VTE score
Elizabeth Boggs
You mentioned that patients on HFNC require days to weeks to wean off- what do you consider threshold for non-improvement to consider other etiologies?
Gaby Frank
I would say it is variable and similar to non-covid patients. If you believe that patient was improving and there is a sudden change, it is worth looking to rule out associated/ new etiologies ( PE, bacterial superinfection. pneumothorax, etc)
Gaby Frank
Pulsox are around $10 in Amazon
Peter Craig
After being in the hospital for a couple of weeks, and upon being discharged, are we seeing evidence that they are still shedding virus?
Gaby Frank
Hard to tell as we are not dong ciral culture ( = live virus) but PCRs which only identifies viral particles
Christine Swanson
Naive question - what does the HEATED oxygen do?
Amiran Baduashvili
We do see prolonged PCR positivity, however, it is unclear whether PCR positivity is associated with live viral shedding
Thank you all!
Sharon Hendricks
Yes Thank You !!!
Gaby Frank
thank you all for participating and all your thoughtful questions