You referenced a modified dose to conserve the medicine,
Do you have any insight on current and future availability ?

Was told by local rep 10 days ago Genentech had large stockpile. Don't know about today. I expect it to be in high demand.

Marcus Aurelius said:

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I find it kind of interesting the amount of fascination in the self-extubation part of the anecdote.

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As a nurse with lots of ER experience I do too.

This is amazing news! To be able to apply something discussed here and see positive results is awesome. How do you get the word out to the rest of the medical community?

At least one other IL-6 inhibitor out there: siltuximab, (Sylvant by Jannsen).

Not sure if it would work as well as toxi, and inventories are likely lower since it only treats orphan diseases.

Others in trials.

BusterAg said:

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At least one other IL-6 inhibitor out there: siltuximab, (Sylvant by Jannsen).

Not sure if it would work as well as toxi, and inventories are likely lower since it only treats orphan diseases.

Others in trials.

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I've used siralumab in addition to toci, both seem to have similar efficacy

Dosing ?

DuncanAg said:

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oneeyedag said:

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So did patient self extubate with the cuff inflated? If so impressive and dangerous.

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Exactly what I was thinking...still inflated? I've obviously never seen that in an EMS setting.

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Self extubation basically always happens with the cuff inflated. It's unplanned.

And generally, the patient suffers no long term ill effects from the cuff trauma. What's not uncommon is they sometimes have to go right back on the vent because they really weren't ready to fly on their own.

Marcus Aurelius said:

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First experience with it. Patient with COVID-19 cytokine storm- typical ARDS high support vent. Fever, all typical inflammatory numbers climbing. Toci (IL-6 inhibitor) at 4mg/kg (to try to preserve drug - normal 8mg/kg dose) given. Next day. All inflammatory markers markedly lower. Patient self extubated and has remained off the vent with O2 support. Promising. Pure anecdote but thought I'd share.

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How old is the patient?

Marcus Aurelius said:

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Gimme a rain check. I have patients tomorrow AM. Thanks for invite.

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Just wrapping up the webinar from Wuhan Central Hospital. It was difficult to follow at times, some of the Chinese MDs had limited English. My Mandarin is limited to a few words, none of which came up during the webinar.

A few things I found interesting about their management:
They were doing 4 - 5 chest CT scans on their patients over the course of hospitalization. Seems like a lot of risk during transport, both in terms of virus spread to medical providers and risk for other "adverse events" during transfer.
They were doing a lot of bronchoscopies with lavage on their intubated patients, and they were also traching patients. Again, a lot of risk.
Mortality rate for intubated patients was/is 70%.
Strongest risk for needing intubation was RR greater than 30/min, others were 50% progression on serial chest radiology findings, 93% sat or less on RA, continuously decreasing lymphocyte count, marked increase in IL-6, CRP, D-dimer, LDH.

They gave steroids whenever SpO2 dropped below 93% at rest on RA, RR over 30, and PaO2/FiO2 less than 300 mm Hg.
Their antiviral drug regimen was Ribavirin 500 BID and Lopinavir/ritonavir 200/50 BID


Standard antiviral treatment (I assume for floor patients as well as in ICU) was
Alpha-interferon atomization 5 million U BID in sterile water
Lopinavir/ritonavir orally 2 capsules each BID
Ribavirin IV drip 500 mg BID - TID
Chloroquine phosphate 500 mg BID
Arbidol 200 mg TID
Further therapy was:
Methylprednisolone 40 mg IV BID, 20 mg "immunoglobulin" QD, and thymosin 1.6 mg Q 3 days, Moxifloxacin, Cefoperazone, and Linezolid, and LMWH 4,000 U daily.

At the end of this page was the bolded warning:
"Be cautious of side effects of these drugs, and combination of more than 3 kinds is NOT recommended".

They are seeing patients who have recovered who continue to test positive, stated about 15% will.
They have very limited experience with convalescent plasma.
They are doing trachs on patients ventilated over 7 - 10 days (again, seems really risky to everyone involved, but I suppose that is why they bronch so often).
D-dimer greater than 1 was and is a huge predictor of death. They anticoagulate all patients without contraindications.

Hmmm. THX. No IL-6 inhibitors? I totally disagree with bronchs BTW. No utility and super high risk. Early trachs also very bad idea IMO. Why multiple CTs? How does that change mgmt and high risk / exposure / transport.

I agree about the trach issue. Maybe they are doing that because they are also doing a lot of bronchs/lavages. They did adapt prone and lateral positioning of their intubated patients.

All I understood was the CT scans part. That's a lot of CT scans. At 7-10 mSv a pop for a chest scan that's twice the background radiation for a whole year.

But if you're hell bent on not dying this instant, slightly raising your lifetime cancer risk is a small price to pay.

Kool said:

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Marcus Aurelius said:

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Gimme a rain check. I have patients tomorrow AM. Thanks for invite.

---

Just wrapping up the webinar from Wuhan Central Hospital. It was difficult to follow at times, some of the Chinese MDs had limited English. My Mandarin is limited to a few words, none of which came up during the webinar.

A few things I found interesting about their management:
They were doing 4 - 5 chest CT scans on their patients over the course of hospitalization. Seems like a lot of risk during transport, both in terms of virus spread to medical providers and risk for other "adverse events" during transfer.
They were doing a lot of bronchoscopies with lavage on their intubated patients, and they were also traching patients. Again, a lot of risk.
Mortality rate for intubated patients was/is 70%.
Strongest risk for needing intubation was RR greater than 30/min, others were 50% progression on serial chest radiology findings, 93% sat or less on RA, continuously decreasing lymphocyte count, marked increase in IL-6, CRP, D-dimer, LDH.

They gave steroids whenever SpO2 dropped below 93% at rest on RA, RR over 30, and PaO2/FiO2 less than 300 mm Hg.
Their antiviral drug regimen was Ribavirin 500 BID and Lopinavir/ritonavir 200/50 BID


Standard antiviral treatment (I assume for floor patients as well as in ICU) was
Alpha-interferon atomization 5 million U BID in sterile water
Lopinavir/ritonavir orally 2 capsules each BID
Ribavirin IV drip 500 mg BID - TID
Chloroquine phosphate 500 mg BID
Arbidol 200 mg TID
Further therapy was:
Methylprednisolone 40 mg IV BID, 20 mg "immunoglobulin" QD, and thymosin 1.6 mg Q 3 days, Moxifloxacin, Cefoperazone, and Linezolid, and LMWH 4,000 U daily.

At the end of this page was the bolded warning:
"Be cautious of side effects of these drugs, and combination of more than 3 kinds is NOT recommended".

They are seeing patients who have recovered who continue to test positive, stated about 15% will.
They have very limited experience with convalescent plasma.
They are doing trachs on patients ventilated over 7 - 10 days (again, seems really risky to everyone involved, but I suppose that is why they bronch so often).
D-dimer greater than 1 was and is a huge predictor of death. They anticoagulate all patients without contraindications.

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Any efficacy discussion? Especially for Chloroquine phosphate 500 mg BID?

Like Caesar Aurelius said, it is strange the they said nothing about IL-6.

Chloroquine was in their regimen. Not a lot of efficacy data presented

I found out during a hospital stay a couple years ago that I'm immune (or whatever you call it) to opioids. They just don't have any effect on me, other than making me a little queezy.

Makes me worried that if I ever needed to be intubated, I'd end up pulling it out.

Fortunately, I know that propofol works on me.

I wouldn't worry about that at all. As they say, particularly where I do peds cases, "anaesthesia always wins". You just have to give more to some than others. Self extubation is never what you are aiming for, you usually want to wean anaesthesia/sedatives/hypnotics, let the patient spontaneously breathe, wean vent settings, then be there and ready if they don't "fly" when they come off the ventilator. But, in the case from Dr. Aurelius' patient, it was a VERY welcome outcome. The strength to put a fight is a good thing. Other than pissing off some ICU nurses, it usually doesn't do too much damage, either.

NL was 40??? Wasn't the level of 100% fatality rate reported from clinical observations >20?

If so that is incredible

Incredible. Just one data point but wow. Thanks for posting.

Now this is good news. A legit therapeutic treatment that's already past FDA safety trials would be fantastic.

Fantastic

How widespread is this being tried??