What to do while waiting for covid immunization?
ICUs reduce mortality in critically ill patients while waiting for specific drugs to arrive
BarcelonaAntivirals, anti-inflammatories and anticoagulants. And oxygen administered in a variety of ways. And, of course, medical and nursing staff, as well as cleaning and other professionals. The formula is the same today as it was in March 2020, when the first wave of the pandemic began. However, there have been substantial changes that have drastically reduced mortality in ICUs and that make specialists look at the future with moderate optimism until the vaccine takes effect. The main one is the greater knowledge of the disease and its complications. The second is the improvement of care circuits. And the third, but no less important, is the availability of the necessary medical equipment.
At the beginning of the pandemic, according to what the emergency services experts explain, they did not "even have PPE" (personal protection equipment), Rafael Máñez, head of the intensive care medicine service at the Hospital de Bellvitge, recalls. "Now we have ventilators, space, and a much better knowledge of how to treat complications arising from the disease", he explains. What is still missing are specific drugs to combat it.
"The patient comes to us much better classified from primary healthcare, and hospital circuits have been redefined", Benito Almirante, head of the infectious diseases service at the Hospital de la Vall d'Hebron in Barcelona, explains. For the expert, the incorporation of outpatient clinics, at any level, has allowed a substantial improvement in the covid patient. "The patient already comes to us diagnosed, which allows us to direct him or her to the hospital area that can offer the best service".
Let's go back to the beginning. What treatments are available in case of need? "Antivirals, anti-inflammatory drugs and anticoagulants", Pedro Castro, head of intensive care at the Clínic, dictates. "Basically, dexamethasone and heparin, both commonly used in hospitals for decades, and some antivirals of uncertain outcome". The great issue is still the lack of "fairly effective" antivirals. Dexamethasone is the chosen anti-inflammatory medicine, and is administered when the virus has caused the immune system to respond excessively, which results in inflammation of the lungs; heparin, also an old acquaintance, is given to prevent thrombus formation, especially in the legs, which can travel to the lungs and cause an embolism.
However, there are almost no new antivirals on the world market. "We administer remdesivir, but we know that it is only effective in an early stage of the disease", Máñez regrets. The benefit of this drug is that it reduces the patients' stay in the ICU, as long as his or her condition has not deteriorated excessively. The rest, says Almirante, is still in clinical trial phase, from specific monoclonal antibodies, such as the one administered to Donald Trump, to other formulas such as the convalescent plasma being researched by Grifols. "Right now there are more than 200 studies on antivirals underway", he explains.
With all these tools -plus oxygen, which is applied with greater or lesser intensity depending on the needs-, ICUs have managed to reduce the desperate mortality of the beginning of all, which was above 80% for those who entered, to an average of between 15% and 20% today. In most cases, this involves patients who are over 70 years of age and have with previous pathologies. For them, death is not so much due to the virus as to the associated complications, especially bacterial superinfections and, to a lesser extent, embolisms caused by thrombi. For the rest of patients admitted to hospital, the protocol currently followed, despite being heavy, has reduced mortality, length of stay and the occurrence of complications, as specialists celebrate.