Thread by @AmitGoyalMD

ACC/CCA COVID Webinar - Serious Illness.

Hope everyone can join!

This will pair very well with @CardioNerds Episode #20 on COVID in the ICU: cardionerds.com/episodes/covid…

Starting off with a case presentation.

31 M p/w fever, cough. from Wuhan

H/o DM & HLD

T 38.5C, HR 152, RR 24, BP 134/107

⬇️wbc & plt
⬆️CRP
🤒CT with patchy opacities including ground glass

Bloodwork.
CT.

Diagnosis

💊Treatments

Takes a turn for the worse

💔Heart Failure by Day 2, LVEF 60%, nondilated

💊Diuretics, Digoxin, Morphine, BiPAP

Bloodwork trends...

Note: lymphopenia, thrombocytopenia, inflammation

⬆️pro-BNP, TnI, LFT, D-dimer --> WHY?

😷There is multorgan dysfunction.

🧐Why is there heart failure?
- hypoxic injury? myocarditis?

Echo seems ok on face value.

But clincial presentation with heart failure and hypotension seems out of proportion...why?

Thankfully, with dilignet supportive care, patinet makes a recovery 🙏

But many questions remain..
- why proBNP and TnI elevation?
- why d-dimer elevated?
- best treatment plan?
- role of anti-inflammation Rx?

Ongoing study of Tocilizumab, anti-Il-6 Ab.

Now let's pivot to the use of ECMO with Prof Ning Zhou MD PhD

Wuhan is the epicenter of this epidemic.

BUT, the # of NEW confirmed cases today - March 19 2020 is...

ZERO! 🙏

Sadly,

~20 of COVID-19 patients --> SEVERE or CRITICALLY ill🥵

1. Resp failure
2. Shock
3. Multiorgan dysfunction

What to do if hypoxic respiratory failure is refractory to mechanical ventillation?

Ans: ECMO!

Let's tackle a case (next)

50 yo M p/w fever and sob. From Wuhan with known COVID-19 contacts.

Hypoxic with infiltrates & groung glass on CT

Labs:
- ⬆️hsCRP, LFT, NT-proBNP, TnI, PO2
- ⬇️Lymphocyte

TTE: EF 45%

Rx:
- anti-bacterial
- anti-viral
- asthma Rx and respiratory clearance
- nutrition
- chinese traditional Rx

BUT: rapid worsening of respiratory failure --> ARDS

- Prone position ventillation --> hypoxia
- Lactate rising

NEXT?

--> VV-ECMO

Thankfully,

Imroving with max support on VV-ECMO x10 days

Result: another patient saved

Great work team!

So far they've had 5 patients on ECMO

4 recovered, 1 ongoing
4 VV-ECMO, 1 VA-ECMO
Duration ~9.2 days, range 6-13 days

Lessons learned:

✅Indications:
- not standard, don't wait for last resort
- need to lower threshold
- don't wait for severe hypoxia which leads to multiorgan failure
- don't do ECMO when patient is dying

🚫Contraindications:
- bleeding (need anticoagulation)
- irreversible severe brain injury
- poor outlook: deathly ill, advanced age

Don't have ECMO for everyone...we have to choose patients who are more likely to recover

⏳When to start ECMO:
- earlier is probably better, if progression is ominous
- if wait too long, may loose the chance to recover them
- ECMO is not just to prolong life for couple days...want to use for SURVIVAL 👏

⚖️Which ECMO?

1st is VV-ECMO - for severe respiratory failure not responding to mechanical ventillation

BUT if cardiac dysfunction 💔 --> don't forget they may need a VA-ECMO

Intubation and mechanical ventillation:
- risk of transmission
- resource limitation
- interrupts airway clearance

Is there a place for VV-ECMO without intubation⁉️

Hmmm...🤨

Something maybe worth considering.

"I would like to say thank you to my patients...

...they are the heros of my city" (Wuhan, China)

I personally am in awe of these incredible doctores, on the frontlines, not just battling COVID-19 in the wards, but taking the time to describe their experience and teach us globally.

Q: What is indicatin for VA ECMO in COVID-19⁉️

-Not all 🏥have ECMO...limited availability
-Most often using VV-ECMO <-- hypoxemia is #1⃣
-VA-ECMO: ⏫Afterload > bad for ♥️

-BUT: if heart failure 💔 & Hypoxia
--> VA-ECMO + Impella

Emphasize: activate VV-ECMO EARLY if patient will likely need it, to prevent worsening. Once they develop multiorgan failure from severe hypoxemia --> may be too late.

ok ok ...so if we need to activate early, but still be judicious...is there a risk score? How do we balance this?

Is there a way to identify the sickest?

Ans:
- no risk score; clinical judgement
- oxygen, lactate, liver & kidney function

Q: How did you monitor inflammatory markers? Daily?

A: CRP (+/-cytokines) & cardiac biomarker

- severe, non-critical: once per week

- ICU patient: every 2-3 days

- severe critical: daily

Q: How did you use Steroid Rx?

A:
- Steroids: active debate in our group
- Possible benefit: may help reduce inflammatory storm
- Possible harm: prolong viral shedding, etc
- Not using commonly