Every COVID week feels unique. The pandemic keeps reforming. This week I began to see patterns of admissions. I’m now thinking that they fall into one of a few types. And since I am a nephrologist and we love three letter acronyms married to a few subtypes I give you Covid Typical Admission (CTA) types 1-3
CTA Type 1 COVID Classic
The patient is either admitted with hypoxia or pretty quickly develops hypoxia. These patients have viral pneumonia and develop profound immune dysregulation. This week, here in Detroit, we are still seeing CTA Type 1 but at a much lower rate than what was crushing us a few weeks ago. A patient is admitted, and may even appear stable to go to the floor, but then they become hypoxic, get intubated, develop profound multi-system disease including ARDS, hypercoagulability, and often AKI. We sometimes can get them stable enough to begin a long, slow, recovery from ARDS or they die in an ugly cytokine storm.
CTA Type 1 Is really hard on the staff. I was talking to a resident because she was canceling a consult she had requested earlier because the patient had since been made comfort care. She commented, that’s it was her fifth death in two days. These kids are seeing more death compressed into a couple of months than I saw in my entire Med-Peds residency.
CTA Type 2. Come in. Get sick. Get better. Get sick again.
These patients are breaking my heart. I tweeted about this last week. (Boy, it feels like a month)
It is soul crushing to see a patient on the vent in kidney failure, and then to see them get better, get extubated, transfer out of the ICU, start discharge and disposition planning, and then see them slide back, get sick and die. Placement is difficult. Finding subacute rehab or long-term care is tough when you have COVID-19. Everything takes a few more days and I’m seeing people deteriorate during the delay. In my mind I have already tallied these patients as ones the virus didn’t get. These are patients that are a win, right up until they get snatched away.
It’s a sucker punch. And it hurts.
CTA Type 3. Patients being READMITTED with a previous diagnosis of COVID.
This week I started to see patients admitted who has already been admitted here or elsewhere and diagnosed with COVID-19. Apparently, the index hospitalization was at the beginning of the illness. They had pretty mild disease and were sent home without an oxygen requirement. But now 4, 8, or 10 days later they are being readmitted after they failed to shake the disease. Of course CTA Type 3 walks hand-in-hand with Type 2. These are the patients where there wasn’t a delay in discharge. They were able to make it home or a sub acute rehab facility. But the virus didn’t get better. They got sick again. The First discharge seemed like a win, but we were looking at a premature outcome.
A lot of these rE-admissions seem pretty benign. A fair amount of altered mental status. Some hypoxia that is easy to treat with nasal cannula oxygen. Some falls with mild trauma. I don’t have a good feel for how sick these people will get, but so far, it seems pretty mild. But this disease is teaching me not to turn my back.
Update on Remdesivir
And since I will always be chained to this infamous tweet, I will comment on the two remdesivir trials that dropped today.
It is these CTA type 2 and type 3 people where I hope that remdesivir has potential. People in the ICU, people that are in the middle of the cytokine storm are not going to benefit from an antiviral. We don’t care about the match once the house is on fire. But earlier in the course, the drug might abort future catastrophes. I hope that if we start treating future CTA Type 3 patients during their index admission we will derail them from severe disease.
Today’s Lancet paper
This Lancet publication was leaked last week, but today we get to see the manuscript. It is a negative study but it is not all terrible. There are some glimmers of hope peaking through the darkness.
I think the data teases that early therapy could be where this drug has promise. Giving the drug later could be like trying to give vanco and cefipime in the middle of sepsis:
an effective therapy given too late to be an effective therapy.
The other remdesivir data is more promising, this larger study of 1000 patients was stopped early because the drug was meeting it’s primary endpoint. The data safety monitoring board (DSMB) just met on April 27 (two days before the press release), so to say it is early is a bit of an understatement. The early bird is still hitting the snooze button. The positive finding was a shorted duration of illness: 15 days for placebo, 11 for remdesivir. Mortality did not meet significance, but the trend makes me excited. I also expect these numbers change as we get more follow up. See CTA Type 2 and 3 above.
I back calculated the number of deaths by using the percent mortality times half the N of 1063. 42 deaths with Remdesivir, 61 deaths with placebo.
