Stony Brook Medicine’s Surgery Team Attacks COVID-19 From Every Angle

Highlights:

• SBM developed an anticoagulation protocol to help prevent blood clots in COVID-19 patients. The ICU team says most Stony Brook patients enrolled in the clinical trial have been able to come off a ventilator with many even being released from the ICU and are now home recovering.
• The team extended the protocol further into the post-discharge period so that patients are protected from blood clot formation with anticoagulants until they are fully recovered from their severe COVID-19 infection.
• Stony Brook University Hospital’s Surgery-Critical Care team found secretions can create an obstruction in the endotracheal tube (ETT) of COVID-19 patients on a ventilator for several days. Keeping this tube clear can prevent the serious consequences of the ventilator not delivering the correct rate, pressure and volume to the patient.

STONY BROOK, NY, May 15, 2020—Since the beginning of the coronavirus outbreak, Stony Brook Medicine (SBM) has been at the forefront of developing new procedures to help improve the outcomes of COVID-19 patients. 

At Stony Brook Medicine, more than 1,200 patients have been hospitalized for the treatment of COVID-19 since the beginning of the outbreak in New York State. Among these patients, more than 25 percent have required admission to the ICU, and the vast majority of those required mechanical ventilation. More than half of the COVID-19 intensive care unit patients being hospitalized at Stony Brook Medicine are being cared for by surgical faculty and surgical residents, with the core team monitoring this disease around-the-clock from the very start. 

According to Mark Talamini, MD, Chair, Department of Surgery, SBM’s surgical team has been able to save more lives and significantly reduce mortality rates by identifying issues early in the pandemic and quickly pivoting to protect those at highest risk.

Here are some of the team’s findings that have helped to improve outcomes:

Anticoagulation protocol rolled out for hospitalized COVID-19 patients

Stony Brook Medicine’s Vascular and ICU COVID-19 team, led by Apostolos K. Tassiopoulos, MD, developed an anticoagulation protocol in mid-March, which was first introduced with a clinical trial and now is implemented hospital wide. Anticoagulants are medicines that help prevent blood clots.

“Our team developed an aggressive protocol for anticoagulation treatment that would escalate based on D-dimer levels,” said Dr. Tassioupoulos. D-dimer levels are measurements of the protein fragments produced in the body when a blood clot gets dissolved in the body.

“A significant increase in D-dimer levels has been noted in hospitalized COVID-19 patients and there are early reports that have linked higher D-dimer levels to worse outcomes,” said Dr. Tassiopoulos. “We believe that the increase in D-dimer levels reflects a more severe prothrombotic state — which means there is an increase in the risk of dangerous blood clots forming in the large or small blood vessels of the body.”

Blood clots can lead to life-threatening conditions, such as end-organ function deterioration; deep vein thrombosis (DVT) leading to fatal pulmonary embolism (PE); and life- or limb-threatening thromboses in the arteries causing strokes, heart attacks or amputations in otherwise low-risk patients.

At Stony Brook, every COVID-19 positive patient or patient under investigation (PUI) for the disease who is admitted to the hospital has a D-dimer level drawn and, based on this initial result, the patient is placed on the appropriate anticoagulation regimen. D-dimer levels are watched daily, and the anticoagulation treatment is appropriately adjusted.

Dr. Tassiopoulos says most patients at Stony Brook enrolled in our anticoagulation clinical trial protocol have been able to come off the ventilator and many have been released from the ICU and are now home recovering, including one patient who was severely immunocompromised with multiple risk factors.

The team has now extended the protocol further into the post-discharge period so that patients are protected from blood clot formation with anticoagulants until they are fully recovered from their severe COVID-19 infection.

Obstruction caused by tissue sloughing from the lungs of COVID-19 patients

Led by Critical Care and Emergency Surgeon Jerry A. Rubano, MD, with his colleagues from Stony Brook’s Division of Trauma, Emergency Surgery and Surgical Critical Care; Vascular and Endovascular Surgery; Pathology; Anesthesiology; and Pulmonary and Critical Care Medicine, the team found there is a potential sloughing of the tissues in the lungs of COVID-19 patients on a ventilator for several days. According to Dr. Rubano the secretions become so tenacious that they can create an obstruction in the endotracheal tube (ETT) that connects the patient’s trachea to the ventilator. His team found early identification of impending complete obstruction can prevent serious consequences and allow for immediate improvement in oxygenation and ventilation. This obstruction occurs, they found, much more commonly in COVID-19 patients.

When looking at a representative sample, the pathology report demonstrated high density consolidations with evidence of sloughing (the shedding of cell tissues) from the tracheobronchial (respiratory) tree and the pulmonary parenchyma, a portion of the lung. This can cause severely impeded ventilation in intubated patients who are several days into the critical course of the disease due to what appears to be tissue sloughing with resulting endotracheal tube obstruction.

“During the hospitalization of COVID-19 patients in our ICU, we’ve found that there can be substantial variations in their required ventilatory support,” explained Dr. Rubano. “Thorough assessment in a subset of these patients yielded concern for acute airway obstruction in the ETT tube. When these partial or complete occlusions were removed, there was almost immediate improvement in oxygenation and ventilation.”

The team recently published its findings in the Annals of Surgery.