Doesn't look like anything we haven't seen before, but in the interest of disseminating information from credible sources: My colleagues in anesthesia at BIDMC had a conference call last week with Wuhan ICU docs and emailed me this summary of their conference call. I confirm
that this email came directly to me from a longstanding colleague (Dr. OG) at BIDMC in Boston and am pasting it unedited. [Please follow similar etiquette of name and attestation when forwarding info, to limit bad information]
1) Natural History: The course of coronavirus appears to be quite prolonged in the patients who end up critically ill. It can take 5-7 days from time of initial symptoms to develop respiratory distress and hypoxemia and about 10 days until patients require ICU admission.
If patients are less severely ill and are ok on nasal cannula alone usually these patients get better over the next 10-14 days. If patients become more hypoxemic and require intubation, it can take 2-3 weeks for recovery.
It appears the pathology while not fully fleshed out is consistent with DAD and typical ARDS in the patients who are mechanically ventilated. Patients initially can worsen in a “silent hypoxemia” phase where they do not look too bad clinically but have pretty severe V/Q mismatch
and hypoxemia, and the early phase of the disease is more hypoxemia alone. As the disease progresses it becomes a mixed hypercapneic and hypoxemic failure as the dead space fraction worsens. While some patients can be quite stiff, this is not universally the case and some
patients may have severe hypoxemia without significant decreases in compliance/increases in driving pressure. Development of AKI appeared common in the ICU population in 10-30% of patients some of whom require CVVH. The disease tends to spare hemodynamic effects without
significant hypotension at least in the early phases (although this is somewhat in contrast to what we had heard from Italy). There is some concern for cardiac toxicity with roughly 30-50% of patients having elevations in troponins, and the presence of cardiac toxicity the
intensivist thought correlated with mortality. Bacterial and fungal superinfection appears to be uncommon overall.
2) Treatment: In their experience early intubation seems to improve patient outcomes. Because of limited resources they were forced to use high flow in some patients for longer than they would have preferred and there was concern in these patients for increased transmission
as well as suboptimal control and worsened outcomes. They found that proning appears to be very effective in the more critically ill patients and 70-80% of patients had a “good” response to proning in terms of oxygenation, and they utilized a similar approach with 16+ hours of
proning per day. They also found they were able to avoid paralyzing patients more often if intubated earlier as the severity of their disease appeared to be less. In the “late” intubations, the use of paralytics was increased. They do not have inhaled NO in Wuhan, so were
unable to comment on differences between veletri and iNO. There was differing opinions as to the utility of recruitment maneuvers and high PEEP levels between the Wuhan clinicians. The response to steroids is unclear. Although 60-70% of vented patients received steroids, there
was unclear benefit from this, and the clinician we spoke to thought that longer term it may have resulted in more prolonged viral clearance and slower recovery even if patients appeared briefly to benefit initially. They have used several antiviral medications
(including remdesevir), but did not feel like they could recommend their use and were unsure of their benefit. They suggested a conservative fluid management approach as most patients were relatively preserved from an HD perspective. Regarding initiation of ECMO, they found
that patients did not seem to do better with early ECMO initiation, and they used it more in a salvage approach, but also used this approach because of limited resources. Most patients were treated up front empirically for CAP/HAP, but the benefit of this was unclear, and
generally longer courses of antibiotics in most patients were not suggested 3) Prevention: Overall health care worker protection has been important. Because of the numbers of patients they were unable to sequester patients to specific areas of the hospital as essentially
the entire hospital became a COVID hospital. They routinely use N95 and face shields for all interactions with patients, but they mentioned that PPE use was variable across different hospitals. Additionally they barred all visitors from coming to prevent further spread. They
also agreed with early intubation and limiting NIV and BiPAP as much as possible. They routinely use humidified circuits with a filter on the expiratory tube to limit spread in ventilated patients. /end
