Weekly Update: January 20th to January 27th 2021

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Welcome to the McGraw-Hill COVID-19 channel. This week we have information on the outcome of treating cardiac arrest on the scene versus transporting the patient to the hospital (a protocol that has been adopted in some areas). This discussion is paired with a British Medical Journal (BMJ) note that England’s health and social secretary has rejected a call for indemnity for physicians who have to make resource allocation decisions. We have new information about anaphylaxis with the Moderna vaccine (exceedingly rare) and information on liberalization of the timing of the second vaccination.

“Do not transport” orders are medically justifiable in out-of-hospital cardiac arrest patients who do not have a return of spontaneous circulation at the scene. As hospitals become overwhelmed with COVID-19 patients, decisions will have to be made about the use of limited resources and how to allocate them. For example, should ventilators be used with patients on a  “first come first serve” basis, or should there be criteria that exclude someone from being intubated? In response to the moral and legal peril posed by having to make these decisions on a day in and day out basis, a number of physician organizations in Great Britain petitioned the government to indemnify physicians having to make these judgments. This request was denied. The BMJ summary can be found here.
Some systems in the United States have changed their transport criteria for cardiac arrest, asking that patients with a poor prognosis not be transferred as a way to alleviate crowding in the ED and the use of inpatient beds. This study supports that decision.  This is a cohort study of 27,750 consecutive patients with an out-of-hospital non-traumatic cardiac arrest. They looked at survival when resuscitation was done only at the scene versus when patients were transported during the arrest. Patients were propensity matched. Survival was 8.5% when resuscitation was done at the scene versus 4.0% 4.6% [95% CI, 4.0%- 5.1%]) if the patient was transported. Neurological outcomes were also better in those resuscitated at the scene. This can possibly be explained by the pauses in resuscitation effort required to move the patient, etc. Of the 10 systems providing data, one site did better with transport, seven did worse and two were neutral.
This supports not immediately transporting patients with a cardiac arrest without return of spontaneous circulation (ROSC). Resuscitation was superior when done at the scene and we can avoid possible SARS-CoV-2 exposure to hospital personnel and alleviate the shortage of bed space. It would be helpful to tease out what was done differently at the site that showed a benefit. But overall, transport during cardiac arrest was harmful. The complete abstract can be found here.

  • Dyer Clare. Covid-19: Doctors’ call for legal protection against claims of unlawful killing is rejected BMJ 2021; 372 :n164
  • Grunau B, Kime N, Leroux B, et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2020;324(11):1058–1067. doi:10.1001/jama.2020.14185

The interval between vaccines can be lengthened to 6 weeks if absolutely necessary according to the CDC. The recommended interval between vaccine doses is 21 days for the Pfizer/BioNTech vaccine and 28 days for the Moderna vaccine. A four-day grace period earlier than these recommendations is allowed. In some circumstance, it may not be possible to meet this schedule. A 21 January 2021 update to the vaccine schedule allows that “the second dose of Pfizer-BioNTech and Moderna COVID-19 vaccines may be scheduled for administration up to six weeks (42 days) after the first dose.” Delay beyond six weeks is not recommended since we do not have data to support a longer delay. However, if the booster shot cannot be given within six weeks, it is not recommended that the series be restarted; just give the second dose as soon as is possible. Complete vaccine recommendations can be found here.
As the number of people eligible for second doses of a vaccine increases, scheduling may be a problem for some patients. This gives us a bit of leeway if it is not possible to meet the recommended schedule.

  • CDC. Interim Clinical Considerations for the Use of mRNA COVID-19 Vaccines Currently Authorized in the United States. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

The risk of anaphylaxis with the Moderna SARS-CoV-2 vaccine is exceedingly low. This is a CDC study of the anaphylaxis risk of the Moderna vaccine based on the first 4,041,396 doses given. There were a total of 10 cases of anaphylaxis (2.5 cases per million, about ¼ of the risk of the Pfizer/BioNTech vaccine). Of these, nine occurred within 15 minutes of the vaccine and there were no deaths (although four had to be intubated). It is notable that 108 cases of anaphylaxis were reported, of which only 10 met the criteria for anaphylaxis.. Both the Moderna and the Pfizer/BioNTech vaccines are exceedingly safe when it comes to anaphylaxis.
You may have heard that there was a pause in vaccinating with one batch of the Moderna vaccine in California. After review, vaccination was resumed using the same batch without problem. The full study can be found here.

  • MMWR. Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Moderna COVID-19 Vaccine — United States, December 21, 2020–January 10, 2021. MMWR Morb Mortal Wkly Rep. ePub: 22 January 2021. DOI: http://dx.doi.org/10.15585/mmwr.mm7004e

 

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