Use of clot-busting tPA on COVID-19 patients in acute respiratory distress

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The woman was dying. New York’s Mount Sinai Hospital was about to call her husband and break the news that there was nothing left to try. Then Dr Hooman Poor took a gamble. According to an AP report, with high-stress, high-stakes decisions, doctors around the world are frantically trying to figure out how COVID-19 is killing their patients so they can attempt new ways to fight back. One growing theory: In the sickest of the sick, little blood clots clog the lungs.

The report says Poor couldn’t prove it. The tests required would further endanger his staff, who were already at risk of getting the virus. But the lung specialist saw clues that were “screaming blood clots.” So, Poor pulled out a drug best known for treating strokes, and held his breath. The report says exactly what’s going on with blood clots in at least some COVID-19 patients is a mystery. Chinese doctors were first to sound the alarm. In March, Chinese heart specialists advised the American College of Cardiology to watch for clots and said certain blood tests showing a rise in clot risk might signal which patients were in greatest danger. Other reports suggested the clots can show up all over the body. But were they a cause of deterioration or an effect?

Already, many hospitals are attempting preventive doses of blood thinners to keep clots from forming. There’s huge debate over what kind to try, what dose is safe – the drugs can cause dangerous bleeding – and how soon to start.

In Mount Sinai, Poor observed the female patient, aged 55, was getting worse. Her organs started failing from the lack of oxygen in her body. The doctors rolled her onto her stomach in a bid to get more oxygen into her body to no avail. Poor decided to combine the blood thinner with a drug called tPA, a plasminogen activator that did not help prevent blood clots but broke them up. 

A few minutes after she was injected with tPA, her oxygen levels rose. She started getting better. The medical staff then decided to put her on a low-dose drip of tPA and blood thinner for 24 hours. To their dismay, the drug only bought time for the woman. She died from a sudden complication days later. 

The medical team tested the same approach on four critically ill COVID-19 patients. One died of cardiac arrest. The other three saw promising improvements in oxygen levels. 

Hospitals in Colorado and Massachusetts are preparing to study whether or not the new drug combination can cure COVID-19 patients. Researchers from the University of Colorado and Harvard conducted a tPA research where they cited three other additional cases where the mixture was also tried. 

Poor first noticed the signs of blood clots in patients who were developing acute respiratory distress syndrome (ARDS)  but whose lungs were not stiff—a sign uncommon in ARDS patients. 

The patients also looked nothing quite like patients suffering from pulmonary embolism. He also found the COVID-19 patients’ hearts were pumping blood regularly. He recalled a rare disease where lung blood vessels abnormally dilate even as others are blocked, which led him to try clot-busting drugs. 

“I did a case series of five,” he said.”It does not prove anything, but it may lead to further research to explain exactly what is going on.”

“We’re taking care of extremely ill patients that are dying in front of us, and we can’t get any diagnostic testing,” yet still have to make treatment decisions, said Dr Steven Pugliese, a lung specialist at the University of Pennsylvania.

The report says Pugliese called Poor’s tPA report “very intriguing” and concluded: “What these doctors did in these very ill patients who were dying was a judgment call, and it was the right thing to do.” But with the bleeding risk, it has to be studied in carefully chosen patients, Pugliese said, especially with no good way to tell in advance who really has these tiny clots.

Full AP News report

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