Editorialblog

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Links dos estudos mencionados neste episódio:

Epidemiology and Transmission of COVID-19 in Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts

Suppression of COVID-19 outbreak in the municipality of Vo, Italy

An analysis of SARS-CoV-2 viral load by patient age

Shedding of infectious SARS-CoV-2 in symptomatic neonates, children and adolescents

Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China

Cluster of COVID-19 in northern France: A retrospective closed cohort study

In my 7 days on one of our (now 12!) non ICU #COVID19 units, I admitted 58 patients for COVID rule out, of whom 50 tested positive. Two died (DNR), 2 went to hospice, and 5 went to the ICU. That is… not my typical gen med service week. Following, some clinical observations.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

My experience perfectly matched published reports. Procal universally low. Ferritin, CRP, d-dimer elevated. Lymphopenia prominent. Patchy infiltrates on CXR. Diarrhea common. So, I want to share some other things I haven’t seen talked about as much.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

1st, I was shocked by the persistence of fevers. My patients had fevers every day, often all day, often >39, for days on end, not especially Tylenol responsive. And they had all had several days fevers before admission.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

2nd, the fevers did not seem particularly related to outcome. In fact most of my ICU transfers did not have persistent fever. They did, however, make patients miserable.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

3rd, this is not your usual sepsis picture. NONE of my patients, even the deaths/ICUs, developed meaningful AKI or liver failure (most had trivial transaminitis). There is no multiorgan failure. Just respiratory failure (I know reported later cardiac; I didn’t see those).

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

4th I did have a bunch of mild troponin elevations, but mostly demand ischemia. No EKGs c/w myocarditis. Suspect too late a complication for me to see.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

5rd, as noted by others, just about all of my patients had had symptoms for 7-10 days before needing admit for O2. This posed a conundrum for the few who were admitted with <5d sx (all on RA) – keep to await nadir? Can’t afford the beds. Had to discharge with warning.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

6th, I found CRP and ferritin often to move in opposite directions (usually CRP ↘️while ferritin still ↗️; CRP leading indicator?). This was confusing. Moreover, I had patients with ferritin >3,000 who did well and others with <800 who struggled. So, not universally helpful.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

7th, as noted by others, these patients deteriorate fast. Really fast. I started calling ICU for any patient who went from RA to 6L in <24 hours; nearly all wound up at least on 100% NRB or high flow if not intubation.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

8th I kept underestimating their exertional hypoxia. Learned my lesson when I transferred one pt to lower acuity floor and he had a syncopal event getting from wheelchair to new bed. Walked all patients with pulse ox prior to d/c.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

9th On the topic of syncope, I admitted 3-4 COVID+ patients with presenting complaint of syncope (2 with head lacs), all early in course, with orthostatic hypotension without significant antecedent fevers. Could COVID be having some effect on autonomic system?

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

10th Our standard protocol right now is azithro/hydroxychloroquine/zinc but I have little faith in efficacy. For the patients I really worried about (fast O2 requirement rise, high inflammatory markers) I gave tocilizumab off label. Clinical trial of sarilumab starting this week.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

11th Proning is now standard in our ICU and I tried hard to get my sicker patients to do it too to head off intubation. This is much harder than it sounds. Most patients couldn’t get into position on their own, found it uncomfortable (back pain), refused.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

12th Most of my patients didn’t eat anything. Partly lack of taste/smell, partly misery with fever, partly hypoxia with exertion, partly lack of visitors/staff in room to encourage and help. Several asked me for soft diet to reduce effort of chewing. Must attend to nutrition.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

13th Lastly, one of the biggest concerns for non-critically ill patients was persistent painful cough. Most had paroxysmal dry, wheezy coughing spasms, often precipitating desaturations. Tried cough syrup, albuterol MDI with spacer (avoiding nebs), codeine, with little effect.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020

Our ICU team has been pushing hard for us to do it on floors - anything to reduce intubation risk. Makes sense. My younger/thinner patients could do it. Very tough for the others especially without staff able to spend long periods at bedside to help.

— Leora Horwitz (@leorahorwitzmd) March 31, 2020