來自西雅圖一線醫生的信息，跟武漢開始的情況很相似了_風聞

在美國西雅圖，人民的希望也不管夠，本來應該給吃10天，現在只能管5天，而且，肝功還要限制狀況特別好的，怪不得招不到臨牀試驗的病人了。醫生抱怨，中國CT可以隨便做，西雅圖沒有那麼多CT資源。 N95口罩都不夠用了，其他護具-面罩？也是清理了再次循環使用。 二十多歲的一樣可以很嚴重，甚至死亡。

Subject: Covid firsthand

Date: March 11, 2020 at 9:02:00 PM PDT

Information Intensivist front line Seattle * we have 21 pts and 11 deaths since 2/28. * we are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen. * US has been past containment since January * Currently, all of ICU is for critically ill COVIDs, all of floor  medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New  resp-sx pts Pulmonary Clinic offshoot is open * CDC is no longer imposing home quarantine on providers who were  wearing only droplet iso PPE when intubating, suctioning, bronching, and  in one case doing bloody neurosurgery. Expect when it comes to your  place you may initially have staff home-quarantined.  Plan for this NOW. Consider wearing airborne iso PPE for  aerosol-generating procedures in ANY pt in whom you suspect COVID, just  to prevent the mass quarantines. * we ran out of N95s (thanks, Costco hoarders) and are bleaching and  re-using PAPRs, which is not the manufacturer’s recommendation. Not  surprised on N95s as we use mostly CAPRs anyway, but still. *terminal cleans (inc UV light) for ER COVID rooms are taking forever,  Enviro Services is overwhelmed. Bad as pts are stuck coughing in the  waiting room. Rec planning now for Enviro upstaffing, or having a plan  for sick pts to wait in their cars (that is not  legal here, sadly). * CLINICAL INFO based on our cases and info from CDC conf call today with other COVID providers in US: * the Chinese data on 80% mildly ill, 14% hospital-ill, 6-8% critically  ill are generally on the mark. Data very skewed by late and very limited  testing, and the number of our elderly pts going to comfort care. -  being young & healthy (zero medical problems)  does not rule out becoming vented or dead - probably the time course to  developing significant lower resp sx is about a week or longer (which  also fits with timing of sick cases we started seeing here, after we all  assumed it was endemic as of late Jan/early  Feb). - based on our hospitalized cases (including the not formally  diagnosed ones who are obviously COVID - it is quite clinically unique)  about 1/3 have mild lower resp sx, need 1-5L NC. 1/3 are sicker, FM or  NRB. 1/3 tubed with ARDS. Thus far, everyone  is seeing: - nl WBC. Almost always lymphopenic, occasionally  poly-predominant but with nl total WBC. Doesn’t change, even 10 days in.  - BAL lymphocytic despite blood lymphopenic (try not to bronch these  pts; this data is from pre-testing time when we had several  idiopathic ARDS cases) - fevers, often high, may be intermittent;  persistently febrile, often for >10d. It isn’t the dexmed, it’s the  SARS2. - low ProCalc; may be useful to check initially for later  trending if later concern for VAP etc. - up AST/ALT, sometimes  alk phos. Usually in 70-100 range. No fulminant hepatitis. Notably, in  our small sample, higher transaminitis at admit (150-200) correlates  with clinical deterioration and progression to ARDS. LFTs typically  begin to bump in 2nd week of clinical course. -  mild AKI (Cr <2). Uncertain if direct viral effect, but notably  SARS2 RNA fragments have been identified in liver, kidneys, heart, and  blood. * characteristic CXR always bilateral patchy or reticular infiltrates,  sometimes perihilar despite nl EF and volume down at presentation. At  time of presentation may be subtle, but always present, even in our pts  on chronic high dose steroids. NO effusions.  CT is as expected, rarely mild mediastinal LAD, occ small effusions  late in course which might be related to volume status/cap leak. * Note - China is CT’ing everyone, even outpts, as a primarily  diagnostic modality. However, in US/Europe, CT is rare, since findings  are nonspecific, would not change management, and the ENTIRE scanner and  room have to terminal-cleaned, which is just impossible  in a busy hospital. Also, transport in PAPRs. Etc. 2 of our pts had CTs  for idiopathic ARDS in the pre-test era; they looked like the CTs in  the journal articles. Not more helpful than CXR. - when resp failure  occurs, it is RAPID (likely 7-10d out from sx  onset, but rapid progression from hospital admit). Common scenario for  our pts is, admit 1L NC. Next 12hrs -> NPPV. Next 12-24hrs ->  vent/proned/Flolan. - interestingly, despite some needing Flolan, the  hypoxia is not as refractory as with H1N1. Quite different,  and quite unique. Odd enough that you’d notice and say hmmm. - thus far  many are dying of cardiac arrest rather than inability to  ventilate/oxygenate. - given the inevitable rapid progression to ETT  once resp decompensation begins, we and other hosps, including  Wuhan, are doing early intubation. Facemask is fine, but if needing  HFNC or NPPV just tube them. They definitely will need a tube anyway,  & no point risking the aerosols. - no MOSF. There’s the mild AST/ALT  elevation, maybe a small Cr bump, but no florid failure.  except cardiomyopathy. - multiple pts here have had nl EF on formal  Echo or POCUS at time of admit (or in a couple of cases EF 40ish,  chronically). Also nl Tpn from ED. Then they get the horrible resp  failure, sans sepsis or shock. Then they turn the corner,  off Flolan, supined, vent weaning, looking good, never any pressor  requirement. Then over 12hrs, newly cold, clamped, multiple-pressor  shock that looks cardiogenic, EF 10% or less, then either VT->VF->  dead or PEA-> asystole in less than a day. Needless to  say this is awful for families who had started to have hope. - We have  actually had more asystole than VT, other facilities report more VT/VF,  but same time course, a few days or a week after admit, around the time  they’re turning the corner. This occurs on  med-surg pts too; one today who is elderly and chronically ill but  baseline EF preserved, newly hypoTN overnight, EF<10. Already no  escalation, has since passed, So presumably there is a viral CM aspect,  which presents later in the course of dz. - of note,  no WMAs on Echo, RV preserved, Tpns don’t bump. Could be unrelated, but  I’ve never seen anything like it before, esp in a pt who had been HD  stable without sepsis. Treatment - *Remdesivir might work, some hosps have seen improvement with it quite  rapidly, marked improvement in 1-3 days. ARDS trajectory is impressive  with it, pts improve much more rapidly than expected in usual ARDS. *Recommended course is 10d, but due to scarcity all hosps have stopped  it when pt clinically out of the woods - none have continued >5d. It  might cause LFT bump, but interestingly seem to bump (200s-ish) for a  day or 2 after starting then rapidly back to normal  - suggests not a primary toxic hepatitis. *unfortunately, the Gilead compassionate use and trial programs require  AST/ALT <5x normal, which is pretty much almost no actual COVID pts.  Also CrCl>30, which is fine. CDC is working with Gilead to get LFT  reqs changed now that we know this is a mild viral  hepatitis. -currently the Gilead trial is wrapping up, NIH trial still enrolling, some new trial soon to begin can’t remember where. *steroids are up in the air. In China usual clinical practice for all  ARDS is high dose methylpred. Thus, ALL of their pts have had high dose  methylpred. Some question whether this practice increases mortality. *it is likely that it increases seconday VAP/HAP. China has had a high  rate of drug resistant GNR HAP/VAP and fungal pna in these pts, with  resulting increases mortality. We have seen none, even in the earlier  pts who were vented for >10d before being bronched  (prior to test availability, again it is not a great idea to bronch  these pts now). - unclear whether VAP-prevention strategies are also different, but wouldn’t think so? - Hong Kong is currently running an uncontrolled trial of HC 100IV Q8. - general consensus here (in US among docs who have cared for COVID pts)  is that steroids will do more harm than good, unless needed for other  indications. - many of our pts have COPD on ICS. Current consensus at Evergreen,  after some observation & some clinical judgment, is to stop ICS if  able, based on known data with other viral pneumonias and increased  susceptibility to HAP. Thus far pts are tolerating that,  no major issues with ventilating them that can’t be managed with vent  changes. We also have quite a few on AE-COPD/asthma doses of methylpred,  so will be interesting to see how they do. Please share