Hospital & ICU VTE prophylaxis,
ARDS ventilatory management,
& administration of experimental agents outside of trials
As a rule, we do not give experimental drugs to healthy ppl without proof, rarely if sick w something where most recover w time, sometimes when hospitalized and most recover w time, and occasionally when critically ill & most don't recover
Is this new condition fundamentally different than conditions I am used to seeing wrt to pathophysiology/ risk?
Let's consider COVID19
Available data is fragmented, cherry picked, evolving and not very persuasive.
Again it is absolutely not clear that COVID is different than the known heterogeneity of ARDS
See this amazing thread
Probably fair to say 96, 97, 98% chance of natural recovery among those diagnosed
The answer is probably no.
There is prima facie no reason, no logic, no evidence to abandon norms/ rules/ practices based on dozens of RCTs to "try something new"
But let's assume the opposite
If you were persuaded thrombosis risk is new, lung pathophysiology is novel, risk of progression is unprecedented, then what you have is a hypothesis..
Like this is a hypothesis:
To answer that you need a randomized trial. Why? Because none of these things are magic bullets.
If they were, someone would report a 100% cure rate. Instead, they at best have meager effect sizes, which need RCT to validate
I think this is different/ new. I think DOAC might be better than enox 40.
See Jeff gets it: He knows these are hypotheses
Not ideas to be implemented
Available data is limited, but outcomes appear grim in this group.
What should we do?
Zinc, Vit C, Toci, Kaletra, Remdesivir compassionate use, even, eculizumab, TPA
If you do this, how will you know if the patient was made better or worse by some, all or a combination of these?
Did they die because of the kitchen sink or despite it?
I mean, we debate TPA in settings where PE is the KNOWN and SOLE cause of illness
Because its harms are MASSIVE and DEVASTATING
Intracranial bleeds horrific.
We debate TPA so much in a setting most favorable for TPA, proven clot, and no other major issue
I find reckless and cavalier
Also, to speak to news reporters whose coverage will only promote off label use, ughh!
Don't speak to reporters about unproven Rx
Yes, we are scared, and yes there is uncertainty, but you don't walk away from decades of VTE guidance, decades of vent management, decades of guiding principles for experimental drugs based on a hunch, a guess, fragmented data, a preprint
Next, you come up with clear hypotheses and
Then, you test them
Testing them is a massive uphill battle.
Most swings in the dark connect with air
Come on, the chance that these maneuvers are going to yield success is vanishingly low, even if rationale is sound
Save cowboy medicine for the rodeo
for all else, RCT