JACC Guidelines for anticoagulation in patients with COVID-19

Outpatient

  • Consider prophylactic dose anticoagulation in patients at high risk of venothromboembolsim and low risk of bleeding,
  • Avoid immobilization
  • Consider transitioning patients taking warfarin to a DOAC

Inpatient

  • Prophylactic dose anticoagulation for all patients without specific contraindications who are not in DIC
  • There is limited evidence to guide which patients require empiric full dose anticoagulation
  • Elevated D-dimer is common in COVID-19 patients; investigation for PE/DVT should be considered in:
    • those with symptoms of DVT
    • acute unexplained RV dysfunction or
    • hypoxemia out of proportion to COVID-19 and/or other underlying lung pathology

Bikdeli, B et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up.

St. Emlyn’s on COVID-19 – Clotting: Diagnosis, D-dimers & Dilemmas

REBELEM on COVID-10 Thrombosis & Hemboglobin


Andrew Morris Update on diagnosis and treatment of COVID-19

Asymptomatic infections are common
We now have two interesting cohorts, out of Iceland  and Italy that about 43% of infections are in people with documented infection are asymptomatic.  We don’t know how well this pairs with “infectious”, but it is a pretty impressive number nonetheless.
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Diagnosis and preventing spread with serology
This is one of these holy grails that has been, unfortunately ignored:  people assume that serology will be really helpful, but experts keep telling us that it won’t be as useful as the epidemiologists think.  There is a real chasm there.  Here is one of several commentaries highlighting that very fact. It is not the most optimistic.
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Medications: we are still at exactly nowhere 
No high quality studies reported, but multiple trials in Canada and beyond.  I think the real problems moving forward are: duplication of efforts, poor coordination, lack of peer review of research, and lack of rationale even.
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Running out of medications for sick patients
Health Canada has a long list of drugs used in critical care on Tier 3 status (i.e. running out!).  This is emerging to be as big a deal (if not bigger) than PPE. It turns out that some COVID-19 patients require massive amounts of intravenous agents:  paralytics, sedative, anxiolytics, and opiates.  It is much more than we anticipated. This will not only affect, potentially, management of patients, but also ability to open up hospitals , and get back to operating.
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Serum therapy
The first serum therapy treatment trials are just starting in Canada: CONCOR-1 and CONCOR KIDs.  A little known fact—you cannot collect or administer serum/plasma therapy in Canada outside of Canadian Blood Services.  This trial is the only way you can get it.
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WHO Prerequisites for ending lockdown and “opening up” economies
The WHO and various countries came out with pre-requisites for coming out of lockdown and opening up their economies. It includes:
  • having the disease under control
  • capacity to test, trace and isolate
  • consideration and assessment of vulnerable populations
  • control of bringing the disease into communities

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Two parallel epidemics
The COVID-19 tragedy has moved from community—> hospitals, to a) long-term care and b) congregant settings (e.g. Shelters, Group Homes, Prisons, etc.).  There are increasingly 2 epidemics in Canada, one being in these congregant settings.  What we really have is an epidemic in the generally central society, and then another one in the marginalized society.  This second epidemic is what will make our struggle to control COVID-19 all that much greater.

AHA Protected code blue algorithm and guideline

AHA Algorithm Protected Code Blue

AHA Protected Code Blue Guidelines


ACEi/ARBs may decrease mortality in patients with COVID-19

Preclinical studies suggest that ACEi/ARBs inhibitors may increase ACE2 expression in the CoV-2 virus, but it is unknown if this occurs in humans or is clinically relevant. The WHO has recommended not stopping ACE/ARBs in patients with COVID-19 despite some earlier recommendations to hold these drugs as a precaution.  Newer evidence suggests that ACEi/ARBs may decrease mortality in patients with COVID-19. This recent retrospective, multi-center observational study in China of 1128 admitted patients with hypertension diagnosed with COVID-19, compared 188 patients taking ACEI/ARB to 940 patients not taking ACEI/ARB, found that the mortality rate was lower in the ACEI/ARB group versus the non-ACEI/ARB group after adjusting for age, gender, comorbidities, and in-hospital medications (adjusted HR, 0.42; 95% CI, 0.19-0.92; P =0.03). Remember, this is an observational study – we should not be starting all COVID patients on ACEi/ARBs based on this one study.

Zhang P, Zhu L, Cai J, et al. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19. Circ Res. 2020.

Thanks to David Juurlink for for the tip on this article


IO is probably a very good option for quick vascular access when wearing full PPE

A recent analysis of RCTs suggests that the use of PPE significantly reduces the efficacy of placing peripheral IVs (RR = 1.0; 95% CI, 0.93–1.08; I2 = 88%; p = 0.006) and extends the time to obtain access (MD = 9.37; 95% CI, 0.81–17.93; I2 = 98%; p < 0.001). They found that IO access was more effective (100% vs 90%) and faster (MD = −17.60; 95%CI,−19.44 to −15.76; I2 = 99%; p < 0.001). They also point out that IO may be associated with a lower risk of stabbing compared to IV.

Smereka J, Szarpak L, Filipiak KJ, Jaguszewski M, Ladny JR. Which intravascular access should we use in patients with suspected/confirmed COVID-19?. Resuscitation. 2020.


The combination of hypogeusia and hyposmia may be helpful in ruling in COVID-19

In an observational study of 452 patients out of France who tested positive for CoV-2 by nasopharyngeal swab hypogeusia (lessened sense of taste) and hyposmia (lessened sense of smell) were strongly associated with COVID-19 diagnosis, separately and combined, in patients with and without a medical history of ENT disorders. A combination of hypogeusia and hyposmia in patients with no medical history of ENT disorders had a sensitivity of of only 42% but had and a specificity of 95%!

Bénézit F, Le turnier P, Declerck C, et al. Utility of hyposmia and hypogeusia for the diagnosis of COVID-19. Lancet Infect Dis. 2020.


Should older healthcare workers and pregnant healthcare workers be excused from work during the COVID-19 pandemic?

People over the age of 60 (especially those with a history of heart/lung disease or cancer and those who are in an immunocompromised state) are at higher risk for both severe disease and mortality from COVID-19, with mortality rates as much 10 times higher in those between the ages of 60 and 69. The literature also suggests that pregnancy is a risk factor for severe disease and adverse fetal effects. ED administrators may consider offering shifts for these staff that do not include the “hot” and “warm” zones of their departments or suggesting that they refrain from ED shifts during the height of the pandemic.

Adapted from CJEM Just the Facts


Other #COVIDfoam Sources of note this week

First10EM deep dive into aerosol and surface distribution of Co-V2

St. Emlyn’s on COVID-19 – Clotting: Diagnosis, D-dimers & Dilemmas

FOAMcast VTE Guidelines & MI

REBELEM Why COVID Screening Protocols Won’t Work

LiTFL Imaging of COVID-19 Pneumonia: A Critical Care Perspective

ERCast COVID-19 Lessons from New York City

EMCrit More COVID Airway

References

Bikdeli, B et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up.

Gudbjartsson DF, Helgason A, Jonsson H, et al. Spread of SARS-CoV-2 in the Icelandic Population. N Engl J Med. 2020.

https://t.co/4mrsdpQL4V?amp=1

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930788-1

https://www.canada.ca/en/health-canada/services/drugs-health-products/compliance-enforcement/covid19-interim-order-drugs-medical-devices-special-foods/information-provisions-related-drugs-biocides/tier-3-shortages.html

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30894-1/fulltext?fbclid=IwAR1lz0MBx_yXL4fN3YPmfaxOnB-

Zhang P, Zhu L, Cai J, et al. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19. Circ Res. 2020.

Chen L, Li Q, Zheng D, et al. Clinical Characteristics of Pregnant Women with Covid-19 in Wuhan, China. N Engl J Med. 2020.

Smereka J, Szarpak L, Filipiak KJ, Jaguszewski M, Ladny JR. Which intravascular access should we use in patients with suspected/confirmed COVID-19?. Resuscitation. 2020.

Bénézit F, Le turnier P, Declerck C, et al. Utility of hyposmia and hypogeusia for the diagnosis of COVID-19. Lancet Infect Dis. 2020;