Salvage use of tissue plasminogen activator (tPA) in the setting of acute respiratory distress syndrome (ARDS) due to COVID-19 in the USA: a Markov decision analysis

被引:30
作者
Choudhury, Rashikh [1 ]
Barrett, Christopher D. [2 ,3 ,4 ]
Moore, Hunter B. [1 ]
Moore, Ernest E. [1 ,5 ]
McIntyre, Robert C. [1 ]
Moore, Peter K. [6 ]
Talmor, Daniel S. [7 ]
Nydam, Trevor L. [1 ]
Yaffe, Michael B. [2 ,3 ,4 ]
机构
[1] Univ Colorado, Dept Surg, Div Transplant Surg, Denver, CO 80202 USA
[2] MIT, Koch Inst Integrat Canc Res, Ctr Precis Canc Med, Dept Biol Engn, 77 Massachusetts Ave, Cambridge, MA 02139 USA
[3] MIT, Dept Biol, Ctr Precis Canc Med, Koch Inst Integrat Canc Res, Cambridge, MA 02139 USA
[4] Harvard Med Sch, Beth Israel Deaconess Med Ctr, Div Acute Care Surg Trauma & Surg Crit Care, Dept Surg, Boston, MA 02115 USA
[5] Ernest Moore Shock Trauma Ctr Denver Hlth, Dept Surg, Denver, CO USA
[6] Univ Colorado, Dept Med, Denver, CO USA
[7] Harvard Med Sch, Dept Anesthesia Crit Care & Pain Med, Beth Israel Deaconess Med Ctr, Boston, MA 02115 USA
关键词
COVID-19; Acute respiratory distress syndrome (ARDS); Tissue plasminogen activator (tPA); Pulmonary failure; Fibrinolysis; Markov; CARE;
D O I
10.1186/s13017-020-00305-4
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Background COVID-19 threatens to quickly overwhelm our existing critical care infrastructure in the USA. Systemic tissue plasminogen activator (tPA) has been previously demonstrated to improve PaO2/FiO(2) (mmHg) when given to critically ill patients with acute respiratory distress syndrome (ARDS). It is unclear to what extent tPA may impact population-based survival during the current US COVID-19 pandemic. Methods A decision analytic Markov state transition model was created to simulate the life critically ill COVID-19 patients as they transitioned to either recovery or death. Two patient groups were simulated (50,000 patients in each group); (1) Patients received tPA immediately upon diagnosis of ARDS and (2) patients received standard therapy for ARDS. Base case critically ill COVID-19 patients were defined as having a refractory PaO2/FiO(2) of < 60 mmHg (salvage use criteria). Transition from severe to moderate to mild ARDS, recovery, and death were estimated. Markov model parameters were extracted from existing ARDS/COVID-19 literature. Results The use of tPA was associated with reduced mortality (47.6% [tTPA] vs. 71.0% [no tPA]) for base case patients. When extrapolated to the projected COVID-19 eligible for salvage use tPA in the USA, peak mortality (deaths/100,000 patients) was reduced for both optimal social distancing (70.5 [tPA] vs. 75.0 [no tPA]) and no social distancing (158.7 [tPA] vs. 168.8 [no tPA]) scenarios. Conclusions Salvage use of tPA may improve recovery of ARDS patients, thereby reducing COVID-19-related mortality and ensuring sufficient resources to manage this pandemic.
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