Patterico's Pontifications

4/22/2020

COVID Patients and Blood Clotting

Filed under: General — Dana @ 2:48 pm



[guest post by Dana]

Yet another awful find about COVID-19 and sick patients:

As the novel coronavirus spread through New York City in late March, doctors at Mount Sinai Hospital noticed something strange happening to patients’ blood.

Signs of blood thickening and clotting were being detected in different organs by doctors from different specialties. This would turn out to be one of the alarming ways the virus ravages the body, as doctors there and elsewhere were starting to realize.

At Mount Sinai, nephrologists noticed kidney dialysis catheters getting plugged with clots. Pulmonologists monitoring COVID-19 patients on mechanical ventilators could see portions of lungs were oddly bloodless. Neurosurgeons confronted a surge in their usual caseload of strokes due to blood clots, the age of victims skewing younger, with at least half testing positive for the virus.

“It’s very striking how much this disease causes clots to form,” Dr. J Mocco, a Mount Sinai neurosurgeon, said in an interview, describing how some doctors think COVID-19, the illness caused by the coronavirus, is more than a lung disease. In some cases, Mocco said, a stroke was a young patient’s first symptom of COVID-19.

Doctors were compelled to develop new treatment protocols:

As colleagues from various specialties pooled their observations, they developed a new treatment protocol. Patients now receive high doses of a blood-thinning drug even before any evidence of clotting appears.

“Maybe, just maybe, if you prevent the clotting, you can make the disease less severe,” said Dr. David Reich, the hospital president. The new protocol will not be used on certain high-risk patients because blood thinners can lead to bleeding in the brain and other organs.

The numbers:

In the three weeks beginning mid-March, Mocco saw 32 stroke patients with large blood blockages in the brain, double the usual number for that period.

Five were unusually young, under age 49, with no obvious risk factors for strokes, “which is crazy,” he said. “Very, very atypical.” The youngest was only 31.

At least half of the 32 patients would test positive for COVID-19, Mocco said.

Meanwhile, Dr. Hooman Poor, a Mount Sinai lung specialist, found himself working a late shift with 14 patients on ventilators. The ventilator readings were not what he expected.

The lungs did not seem stiff, as is common in pneumonia. Instead, it seemed blood was not circulating freely through the lungs to be aerated with each breath.

Poor ran into a kidney doctor that night, who remarked that dialysis catheters were often getting blocked with clots.

“And I said, ‘It’s funny that you mentioned that because I feel like all these patients have blood clots in their lungs,’” Poor recalled.

Doctors throughout the country started noticing the emergence of blood clots in their COVID patients as well. And although blood clots present a common danger for patients immobile for long periods of time, the onset of blood clots in COVID patients appears more rapidly:

Clotting can develop in anyone who gets very sick and spends long periods of time immobile on a ventilator, but doctors say the problem seemed to show up sooner in COVID-19 patients as a more direct consequence of the virus.

Under the new protocols, patients at Mt. Sinai are being given higher doses of the blood thinner, heparin even before clots have been detected.

Just days ago, Broadway actor Nick Cordero, who had been battling coronavirus for three weeks, had to have his leg amputated due to blood clotting:

Cordero, who has been in the hospital since March 31, was being treated with blood thinners to help relieve clotting in his leg, but doctors had to stop the medication because it was causing internal bleeding… On Saturday, the decision was made to amputate, Kloots said, according to the AP.

Losing his leg is just the latest serious complication Cordero has faced after being hospitalized with what was initially thought to be pneumonia, but later turned out to be covid-19, the respiratory illness caused by the novel coronavirus, according to his wife.

On April 12, for example, Cordero “lost consciousness, he lost his pulse and they had to resuscitate him” after a lung infection set off a chain reaction that affected his blood pressure and heart, Kloots said in a now-deleted Instagram story, Variety reported.

The hard reality is this:

Blood clotting has emerged as a phenomenon in covid-19 patients suffering from particularly serious infections, with physicians unsure of what type of treatment is most effective, according to STAT News. While blood clots aren’t unusual in those who are immobile for long periods of time, like people on ventilators, “they seem to be smaller and cause far more severe damage” in patients diagnosed with covid-19, STAT News reported.

As Science Magazine reports, the prevalence of clots may be yet another indication that the novel virus can wreak havoc on the human body far beyond the lungs, which are considered “ground zero.”

The disease “can attack almost anything in the body with devastating consequences,” cardiologist Harlan Krumholz of Yale University and Yale New Haven Hospital told the magazine. “Its ferocity is breathtaking and humbling.”

–Dana

Southern Governors Start to Reopen — But What Is the Plan?

Filed under: General — Patterico @ 8:27 am



Here we go:

Some governors in the South have begun loosening restrictions put in place to contain the spread of coronavirus.

Georgia Gov. Brian Kemp on Monday granted businesses across the state permission to reopen later this week, an announcement echoed by a handful of other Republican governors who are beginning to lift stay-at-home orders.

Kemp’s decision, which will apply to barbershops, gyms and other businesses that include close contact, comes days after President Donald Trump issued guidelines to reopen state economies. Protesters across the country have been gathering at rallies outside state capitals demanding an end to shutdown orders.

In a series of tweets last week, the president called for demonstrators to “LIBERATE” certain states.

There is a set of principles upon which all sane people ought to be able to agree. Of course we can’t because partisanship, but they exist nevertheless.

First, decisions to reopen or not reopen necessarily involve death vs. convenience/jobs/economy calculations, of the sort we have always implicitly made on a regular basis, but which make you look like a moral monster if you put them in black and white. “How many children are you willing to kill to go ten miles faster” is an argument that could be used to reduce our freeway speed limits to 65, or 55, or even 25 mph. It’s only what we are accustomed to that reduces the monstrous appearance of any given approach that says “let’s move forward even though it may kill people.”

Second, the level of social distancing the country is currently experiencing is unsustainable in the long run or even the medium run of 18 months. It has already decimated the economy and will continue to do so, and that has real effects, on standards of living and eventually on death rates.

Third, without widespread antibody and CV testing, reopening too quickly not only will cost lives, but threatens to overwhelm the system catastrophically, in the exact manner that happened in Italy and which we were trying to avoid with this level of quarantine here.

Fourth, if we reopen without a plan, we are not looking at a pure death vs. convenience/jobs/economy tradeoff, because the level of death that could occur in the catastrophic scenario mentioned in point #3 would itself crater the economy.

Fifth, the decision by the Southern governors will cost lives, and the level of death it will cause will not be known for weeks. Whether it’s a good call (and, given point #3, I suspect it’s not) depends not on whether “a single life is lost” (see point #1) but on whether the level of death is shocking and overwhelms the system (see point #3).

Ultimately, it’s raining, we’re holding an umbrella, our arms are getting tired, and we see that we’re not that terribly wet … so we’re closing the umbrella. But that decision should be made, not on the basis of the fact that we aren’t that wet, but how hard it’s raining outside the protection of our umbrella, what our plan is for after we close it, and how bad it is if we get wet anyway.

All I see at this point is people upset that we bothered to use it in the first place because hey, after all, we’re not that wet. Right now.

We need a plan.

We’ll see what happens. I will ignore the inevitable tributes to the wisdom of the governors as nothing seems to change, for a minimum of one month. (Bookmark the post and remind me.) At that point, I think we’ll start to see if my suspicion is right that this is a bad mistake, at this particular point in time.

In the meantime, how about less absurd finger-pointing on testing and some more effort on getting it done? Because this reopening has to happen sometime.

Paging Dr. Trump: NIH Panel Recommends Against Drug Combo President Touted For COVID-19

Filed under: General — Dana @ 6:58 am



[guest post by Dana]

In spite of Trump’s repeated promotion for the use of hydroxychloroquine and azithromycin to combat coronavirus, members of the COVID-19 Treatment Panel have recommended against use of the combination of drugs:

A panel of experts convened by the National Institute of Allergy and Infectious Diseases recommends against doctors using a combination of hydroxychloroquine and azithromycin for the treatment of COVID-19 patients because of potential toxicities.

“The combination of hydroxychloroquine and azithromycin was associated with QTc prolongation in patients with COVID-19,” the panel said.

QTc prolongation increases the risk of sudden cardiac death.

The panel also addressed usage of the two drugs by themselves:

As for using the use of hydroxychloroquine or chloroquine alone, the panel said there was “insufficient clinical data to recommend either for or against.” It reached the same conclusion about the drug remdesivir.

The panel of medical experts, with clinical experience and expertise in patient management, clinical science, and/or development of treatment guidelines, will not make recommendations about a drug’s use if strong scientific evidence is lacking to make a firm conclusion one way or the other:

“It’s all based on the data,” said panel member Dr. Susan Swindells, a professor in the department of internal medicine at the University of Nebraska College of Medine. “We just plowed through everything that was, and apart from supportive care, there wasn’t anything that was working terribly well.”

The panel also concluded that there was insufficient evidence to recommend any kind of treatment either to prevent infection with the coronavirus or to prevent the progression of symptoms in those who are already infectious. That recommendation could change based on clinical trials presently underway.

–Dana

UPDATE BY PATTERICO:


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