Tocilizumab for the Critically Ill With Severe COVID-19: A Community Hospital Case Series.

OBJECTIVE: To evaluate the use of tocilizumab in a community hospital setting for critically ill patients with severe COVID-19. DESIGN: A retrospective case series. SETTING: Five community hospitals within 1 urban health system. PATIENTS: Adult patients whom received tocilizumab between March 27th, 2020 to April 30th, 2020 for severe COVID-19. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixteen patients in total were evaluated from the 5 community hospitals. The mean (± SD) age of the patients was 53.9 ± 9.2 years, 56% were men, and the most common comorbidities present on admission were hypertension (31%) and diabetes mellitus (25%). All patients received at least 1 other treatment modality for COVID-19 (steroids, hydroxychloroquine, or convaslescent plasma). Additionally, all patients on admission to intensive care units had severe COVID-19 with 56% requiring mechanical ventilation with a pre-tocilizumab median (IQR) Pao2: Fio2 of 84 (69 - 108.6), 19% requiring vasopressor support, and inflammatory markers (CRP, LDH, ferritin, and IL-6) were elevated. The median (IQR) tocilizumab dose was 400 mg (400-600) which correlated with a weight-based mean (± SD) dose of 5.4 mg/kg ± 1.3. Of the 16 patients that received tocilizumab, 8 (50%) were discharged home, 7 (44%) died, and 1 (6%) was still hospitalized at the end of data collection. Patients who died were more likely to be older 62 ± 2 years, female (57%), had a higher rate of mechanical ventilation (86%) and vasopressors (43%) use at baseline, and had a higher median (IQR) IL-6 level prior to tocilizumab administration 550 pg/mL (IQR 83-1924). There were no reported adverse drug reactions reported after the administration of tocilizumab for any patient. CONCLUSIONS: Our findings do not support the effectiveness of tocilizumab in treatment of severe COVID-19 infection in critically ill patients.

Anticoagulation of Impella with a Bivalirudin Purge Solution.

The use of percutaneous ventricular assist devices (VADs) in the acute management of cardiogenic shock is becoming increasingly common. The Impella is a percutaneous VAD, which requires a heparin-containing purge solution to prevent thrombosis and maintain proper pump functionality. In this report, we describe two patients with heparin-induced thrombocytopenia (HIT) supported with an Impella using a bivalirudin-containing purge solution. Case 1 involved a 39-year-old man with cardiogenic shock, initially implanted with an intraaortic balloon pump, who developed HIT early in his hospital course. His worsening hemodynamics necessitated the placement of an Impella and later venoarterial extracorporeal membrane oxygenation until he eventually underwent durable left VAD implantation. Case 2 involved a 69-year-old man who had an Impella implanted for worsening cardiogenic shock. HIT was suspected shortly after device insertion, necessitating switching his anticoagulation to bivalirudin. He was successfully bridged directly to heart transplantation. Both patients' courses resulted in therapeutic anticoagulation without major bleeding or thrombotic events. These cases demonstrate the safe and effective use of bivalirudin-containing purge solutions for patients with confirmed HIT requiring temporary mechanical circulatory support with Impella.

Safety and Efficacy of High-Dose Unfractionated Heparin for Prevention of Venous Thromboembolism in Overweight and Obese Patients.

STUDY OBJECTIVE: To determine the safety and efficacy of high-dose subcutaneous unfractionated heparin (UFH) for prevention of venous thromboembolism (VTE) in overweight and obese patients. DESIGN: Single-center retrospective observational cohort study. SETTING: Large academic tertiary care medical center. PATIENTS: A total of 1335 adults who weighed more than 100 kg on admission and received either subcutaneous UFH 7500 units every 8 hours (751 patients [high-dose group]) or 5000 units every 8 hours (584 patients [low-dose group]) for VTE prophylaxis during their hospitalization between January 1, 2013, and August 31, 2014. MEASUREMENTS AND MAIN RESULTS: The incidences of VTE and bleeding complications were assessed in each group. Each group was further divided into four groups based on their body mass index (BMI): overweight (BMI 25-29.9 kg/m(2) ), obese class I (BMI 30-34.9 kg/m(2) ), obese class II (BMI 35-39.9 kg/m(2) ), and obese class III (BMI ≥ 40 kg/m(2) ). The incidence of VTE was similar for patients in the high-dose group versus those in the low-dose group for all BMI categories. Bleeding complications were significantly higher for patients in the high-dose group. The proportion of patients with at least a 2-g/dl hemoglobin drop from admission was higher in patients in the high-dose groups in obese classes II and III: obese class II, 46 (30%) of 152 patients in the high-dose group versus 30 (18%) of 171 patients in the low-dose group (p<0.01); obese class III, 109 (25%) of 432 patients in the high-dose group versus 31 (12%) of 249 patients in the low-dose group (p<0.01). In addition, the proportion of patients who received at least 2 units of packed red blood cell transfusion was significantly higher in patients in the high-dose group who were in obese class III: 47 (11%) of 432 in the high-dose group versus 13 (5%) of 249 in the low-dose group (p<0.01). CONCLUSION: Administering a higher dose of heparin to patients weighing more than 100 kg may not impart additional efficacy in reducing the incidence of VTE. However, it may increase the risk for bleeding.

Effectiveness of protocol guided heparin anticoagulation in patients with the TandemHeart percutaneous ventricular assist device.

The purpose of this analysis is to assess the effectiveness of heparin anticoagulation in cardiogenic shock patients with TandemHeart percutaneous ventricular assist device support for which the institution's TandemHeart heparin protocol was implemented compared to those managed without protocol. This retrospective analysis included 15 patients in the protocol group and 10 patients in the nonprotocol group. Patients in the protocol group had a higher percentage of therapeutic activated partial thromboplastin time (aPTT) and lower percentage of supra-therapeutic aPTT values compared to the nonprotocol group. We conclude that TandemHeart anticoagulation may be more effectively managed through the use of a protocol than without any protocol.