ABSTRACT
INTRODUCTION: Tocilizumab is recognized as a safe and efficacious treatment option for critically ill patients with COVID-19. Controversy remains regarding appropriate criteria for use. This evaluation assessed tocilizumab use for COVID-19 treatment and clinical outcomes following implementation of an institutional guideline. METHOD(S): This was a 2-center (1 community;1 academic), retrospective review of adult patients admitted to the ICU that received tocilizumab for COVID-19. Baseline demographics, length of stay (LOS), mechanical ventilation (MV), morbidity, mortality, and drug cost were collected. C-reactive protein (CRP), ferritin, and lactate dehydrogenase (LDH) were reviewed and compared to institutional criteria for use. RESULT(S): Forty (26 community;14 academic) critically ill patient cases were reviewed. No differences were observed in baseline demographics, with a pool median age and weight of 58 (49-65) years and 102 (88-117) kg, respectively. No difference (community, 4 [15.4%] vs academic, 0 [0%];p=0.28) was seen in vaccination status. No differences were seen in time to tocilizumab administration, dose, hospital and ICU LOS, or progression to MV. Pooled median inflammatory markers included a CRP 131 (92-200) mg/L, ferritin 1074 (418-1936) ng/mL, and LDH 589 (414-803) IU/L with no differences between groups. Median ferritin values were noted as numerically higher, but non-significant in the community group (1331 [614-2306] ng/L vs 555 [341- 1851] ng/mL;p=0.16). Pooled all-cause in-hospital mortality was observed in 14 (35%) patients, with numerically higher, but non-significant rates in the community group (12 [46.2%] vs 2 [14.3%];p=0.08). Median charge per patient was $15,625.55. CONCLUSION(S): Critically ill patients receiving tocilizumab for COVID-19 treatment have high rates of mortality despite early use upon ICU admission. Baseline inflammatory markers were markedly above institutional criteria for use, leading to adjustments in the institutional guideline. Routine evaluation of tocilizumab use criteria may be warranted during strained supplies and COVID-19 surges.
ABSTRACT
INTRODUCTION/HYPOTHESIS: Analgosedation is standard of care in management of patients on mechanical ventilation. Drug shortages before and during the COVID-19 pandemic presented unique challenges, particularly during surges. The purpose of this study was to evaluate the impact of a structured, daily huddle report on analgosedative medication use in mechanically ventilated MICU patients. METHODS: This retrospective, single-center analysis included 3 two-month epochs before (E1), during (E2) and after (E3) initiation of an interprofessional pre-round huddle. Two metrics presented included continuous infusion (CI) analgosedation and drug shortages in effort to identify opportunities for scheduled enteral or parenteral therapies to aid CI weaning. Adult patients admitted to the MICU and on CI analgosedation were included. The primary endpoint compared daily and cumulative scheduled parenteral, enteral, and CI analgosedation administered between epochs. Secondary endpoints included percent-time in goal RASS, Objective Pain Assessment Scale (OPAS), time without delirium, evaluation of drug costs, and effect on ICU outcomes between epochs. RESULTS: A total of 81 patients (E1: 27;E2: 23;E3: 31) were included. Mean age (E1, 65.9±15.4 vs E2, 59.7±10.3 vs E3, 56.3±12.6 years;p=0.021) and proportion COVIDpositive (E1, 0 [0%] vs E2, 6 [26.1%] vs E3, 3 [9.7%];p=0.013) were different between groups. Cumulative CI opioid requirements (E1, 719.5 (214.4-1874.5) vs E2, 641.9 (503.7-1675.9) vs E3, 430.4 (247.2-856.5) mg morphine equivalents;p=0.029) were significantly different. Time on CI fentanyl (E1, 85.9 (46.1-170.5) vs E2, 95.3 (47.2-161.7) vs E3, 41.4 (12.4-67.2) hours;p=0.003) was also decreased. Percent-time in goal OPAS, RASS, without delirium were similar between epochs. Drug cost for CI fentanyl (E1, 3842.1 [1144.9-100009.83] vs E2, 4019.7 [2607.3-8954.4] vs E3, 2208.1 [1321.7-4451.4];p=0.023) was reduced. CONCLUSIONS: This exploratory analysis of a structured approach in scheduling enteral and parenteral agents to wean off CI analgosedation during drug shortages may be effective. Time on, overall CI fentanyl requirements, and costs were significantly reduced while maintaining adequate analgesia and sedation. These results may introduce novel strategies to mitigate drug shortages while maintaining clinical outcomes.