Are we actually treating ARDS in ventilated COVID-19 patients?

[jdh71]

3 positives. All did well. Probably some more PUIs that are false negs or yet to rule in as our turnaround is still > 24 hrs.

My problem with the Cui paper that seems to have started this D-dimer interest is that it was only 81 patients who did not get ppx. Their rate of VTE of 25% was not unheard of historically in patients who didn’t get ppx. We are not yet using the dimer to anticoagulate but who knows what will happen in a week.

The virus definitely has us doing some second guessing. Things go sideways in weird and often unexpected ways. It's very hard to have reflexes as I noted above. I mean I figure I'll pick up some better reflexes with more cases, but this this is just different. I've been personally involved in 7 cases at this point and my group closer to 20. I know we aren't supposed to treat this thing as "exceptional" but it seems to be doing weird stuff.

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[Hernandez]

How much paralytic? Also, unless they get it for you fresh from the fridge, and not some room temperature cart/Pyxis, assume it has maybe 60% of its normal potency.

I give the size of my pts, I rarely give anything other than 100mg of roc.

 

[jdh71]

Another thing we've found helpful for cough on the vent leading too dysynchroyny: phenergan with codeine (don't forget the Senna and colace if you go this route). This has also helped us cut way down on sedation.

It's like, ok . . . fight this new virus, it will do weird stuff and it's scary like winning the ****ty lottery if you get infected (probably be fine but if you're not then you're highly likelihood of being ****ED), please do this while lacking the usual PPE (plan to reuse a lot of it), oh don't plan on your usual diagnostics because everyone wants to save PPE or not risk exposure, and finally . . . since we are running out of the usual sedative medications you always use and we can't source any new stuff, please also figure out a way to to take care of these patients without the use of your usual sedatives thanks (and we may have cut your salary a little, maybe, soooorrrrryyy)

 

[deleted171991]

I give the size of my pts, I rarely give anything other than 100mg of roc.

If that roc is "older", it may not be enough for RSI (1.2 mg/kg). If you prefer not to use sux, I would up that roc dose to 1.5-2 mg/kg, if not from the fridge.

I have never used more than 100 mg either. But I use sux for most of my RSIs (no Covid patients yet, and it's mostly in the OR). I hate using roc when I don't have sedation ready to go at bedside.

 

[ShockIndex]

I give the size of my pts, I rarely give anything other than 100mg of roc.

All of mine did well on HFNC, but my friends have described an edematous, angioedema-like mess on most intubations.

Perhaps I can convince the manufacturers of icatibant to pay me to study their crappy drug in these patients since my salary is being cut? At the very least, they could treat me to a pharmrep dinner at Ruth’s Chris...oh, wait...I forgot...#rolleyes.

 

[deleted171991]

All of mine did well on HFNC, but my friends have described an edematous, angioedema-like mess on most intubations.

Your friends are not alone. A lot of Internet posters mention upper airway edema. Covid intubations should be assumed to be difficult.

 

[ShockIndex]

If that roc is "older", it may not be enough for RSI (1.2 mg/kg). If you prefer not to use sux, I would up that roc dose to 1.5-2 mg/kg, if not from the fridge.

I have never used more than 100 mg either. But I use sux for most of my RSIs (no Covid patients yet, and it's mostly in the OR). I hate using roc when I don't have sedation ready to go at bedside.

Interesting. I grew up using sux in residency but gradually switched to roc when I became an attending because all of the residents called me old school or grandpa. I always asked the pharmacist to pull 1 mg/kg rounded-up to the next 10Kg to make it easy for them. I’ve never thought to ask about temperature effects. You taught me something - thanks. I love heading to bed immediately after learning something new.

 

[deleted171991]

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Also:

 

[Hernandez]

If that roc is "older", it may not be enough for RSI (1.2 mg/kg). If you prefer not to use sux, I would up that roc dose to 1.5-2 mg/kg, if not from the fridge.

I have never used more than 100 mg either. But I use sux for most of my RSIs (no Covid patients yet, and it's mostly in the OR). I hate using roc when I don't have sedation ready to go at bedside.

I have no problems with sux, just can't always verify labs in some of the clusters I walk into.

 

[deleted171991]

Interesting. I grew up using sux in residency but gradually switched to roc when I became an attending because all of the residents called me old school or grandpa. I always asked the pharmacist to pull 1 mg/kg rounded-up to the next 10Kg to make it easy for them. I’ve never thought to ask about temperature effects. You taught me something - thanks. I love heading to bed immediately after learning something new.

Just to be clear: this is what prompted my . I would sleep a lot if I did that.

In this case, the culprit may have been the temperature, it may have been a big patient.

 

[deleted547339]

Your friends are not alone. A lot of Internet posters mention upper airway edema. Covid intubations should be assumed to be difficult.

We had to trach someone because they failed extubation due to stridor three times. I’ve intubated a couple - they were all anatomically normal but desaturated more rapidly than I would expect otherwise.

 

[chocomorsel]

Makes more sense...you were scaring me there for a second.

The way I read it made me think that the patient developed the GI bleed and someone checked a D-dimer (perhaps as part of a DIC panel) and then decided to anticoagulate with heparin when it came back high. I could see the last FM intern doing that who rotated with me in the MICU.

Personally, I’d be very careful anticoagulating these COVIDs just based on a dimer. It’s an acute phase reactant and there is not enough data or power in the Cui paper to create thresholds where benefits outweigh risks. I think that serial, daily POCUS of the legs and echo makes more sense. I’d definitely consider heparin if their echo suggested RV strain, sudden increase in dead space fraction, or pulmonary HTN.

Our radiologist told me he was trying to limit his techs’ exposure to Covid, so no ultrasound.
No joke.

 

[chocomorsel]

3 positives. All did well. Probably some more PUIs that are false negs or yet to rule in as our turnaround is still > 24 hrs.

My problem with the Cui paper that seems to have started this D-dimer interest is that it was only 81 patients who did not get ppx. Their rate of VTE of 25% was not unheard of in historical patients who didn’t get ppx. We are not yet using the dimer to anticoagulate but who knows what will happen in a week.

I do agree that 12K is high though...tough one

10 to 20k is the norm around here.

 

[WheezyBaby]

Our radiologist told me he was trying to limit his techs’ exposure to Covid, so no ultrasound.
No joke.

We lost an entire echo department to quarantine at one of our hospitals

 

[turkeyjerky]

We lost an entire echo department to quarantine at one of our hospitals

Hence the problem with ridiculous quarantine protocols.

See the obgyn study out of New York? 13% of asymptomatic women presenting for induction of labor tested positive for covid. Granted, this is in a (currently) higher prevalence area than most of us practice, however I think it's reasonable to extrapolate it to most hospitals. Which leads to the following conclusions:

1) A significant number of asymptomatic healthcare workers are infected at any given time
2) Since asymptomatic persons can transmit the virus, a significant portion of your coworkers are infectious
3) Thus it is fundamentally illogical to hold people out of work due to an exposure