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In this global war, with all doctors being turned overnight into COVID-19 doctors, our surgical team immediately became a central part of the troops alongside the nurses, respiratory therapists and physician assistants and others who are at the frontline to move the fight forward for those battling severe COVID-19. This playing field is different — requiring the perspective of every medical lens, especially from the vantage of top surgeons.

Over half of the COVID-19 intensive care unit patients being hospitalized at �ǿ����޴�ý are being cared for by surgical faculty and surgical residents, with the core team watching this disease 24/7 closely from the very start. The team is led by Mark Talamini, MD, Chair, Department of Surgery; James Vosswinkel, MD, Chief of Trauma, Emergency Surgery and Surgical Critical Care, who came down with the disease and is now recovered and back to work; Apostolos K. Tassiopoulos, MD, Chief, Vascular and Endovascular Surgery and Vice Chair for Quality and Outcomes; Jerry A. Rubano, MD, General, Critical Care and Emergency Surgeon; Dan Rutigliano, DO, Critical Care Surgeon; and , Director, Surgical Critical Care Residency and Deputy Chief, Medical Information Officer, among others.

“�ǿ����޴�ý’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,” said Dr. Talamini. “Being next to these patients minute-by-minute makes all the difference. We’ve learned a lot about this disease from the surgery team, and I'm proud of their dedication, energy and personal commitment.”

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

Anticoagulation protocol rolled out for hospitalized COVID-19 patients

For those of us who were attentively watching the daily press briefings of our local government in early April, we became all too familiar with this grim outlook: Once you go on a ventilator, there’s only a 20 percent chance that you will come off.

Thankfully, that’s not true at Stony Brook.

Our Stony Brook 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.

“After we assimilated reports from China and Italy and through direct conversation with colleagues in Italy, Spain and France, as well as our own early observation of COVID-19 patients, 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.

“Despite uncertainties, early data both on an international and local level is promising,” said Dr. Tassiopoulos. “At Stony Brook, most of our patients 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 high risk factors.”

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.

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

For patients with severe COVID-19 infection who are on a ventilator, the endotracheal tube (tube placed in the trachea) and ventilator tubing is their lifeline to push oxygen into the lungs. When the ventilator’s built-in protection system signals an alarm, it can be a signal that the machine needs to be dialed up, sending more pressure to properly inflate the lungs: too much runs the risk of lung damage and too little is life-threatening.

Sometimes the simple discoveries can be the most important. The pathophysiology — the way the condition plays out in the body — of this critical illness is being revealed on a day-to-day basis at the frontlines in the Intensive Care Unit (ICU).

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 recently published its findings in the Annals of Surgery.

“We discovered that when patients are on a ventilator for several days — at a median of around day seven — there is a potential sloughing of the tissues in the lungs; 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,” said Dr. Rubano. “Caregivers need to be aware and treat this important aspect of COVID-19 that can occur in advanced stages of the disease. Simply keeping this tube clear of obstruction can prevent the serious consequences of the ventilator not delivering the correct rate, pressure and volume to the patient.”

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.

“With 20 percent of the over 150,000 patients diagnosed with COVID-19 in New York State (as of April 8) needing hospitalization and 25 percent of those hospitalized patients requiring admission to the ICU and prolonged mechanical ventilation, it is vital to understand the disease manifestation and how this can impact the oxygen support needs of these critically ill patients,” said Mark Talamini, MD, Chair, Department of Surgery.

At �ǿ����޴�ý, more than 400 patients have been hospitalized from February through April 2020 for the treatment of COVID-19. Among these patients, more than 25 percent have required admission to the ICU, and the vast majority of those required mechanical ventilation.

“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.”

Learn more about �ǿ����޴�ý’s Department of Surgery.