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I am about to see my first case with high probability. What do you guys do when you get home? Do you quarantine yourself from your family? Assuming you wear full PPE
I am about to see my first case with high probability. What do you guys do when you get home? Do you quarantine yourself from your family? Assuming you wear full PPE
The early experience was no NIPPV due to contamination risks. The Italians have changed that concept, but also look at the "bubbles" they are using for CPAP.interesting. I keep seeing “early intubation” a lot but this guy says their experience with CPAP was very good.
Less than 50% of intubated patients should survive, even with the best of care. It will be depressing like hell. I bet a lot of uncontrolled diabetics will just die (among the patients we'll have to triage out in a few weeks).Is anybody seeing anyone survive after they are intubated? I had my first Covid ARDS patient, mid forties, uncontrolled diabetes A1C>11 otherwise no past medical hx. No asthma hx. Hits the ED desatting on 6L and we tubed him asap. I'm off service now but as I left yesterday pulm spent 2 hours messing with his vent trying to get his oxygenation going and he was proned, paralyzed and on flolan. He had a CRP of 30+ and ferritin of 1000+, and he's on plaquenil/azithro right after tubing, because that's all my community hospital has.
Mid 40s. Only diabetes. Holy ****.
I strongly recommend subscribing to Rob Mac Sweeney's critical care newsletter, for coverage of new critical care papers, including Covid-19. The next issue should come out at the end of the week.
Here's the link:
Registration
Critical Care Reviews is a collection of free, high quality, peer reviewed critical care review articlesmandrillapp.com
Who are "they"? I am pretty sure it's not the IDSA (I don't care about the rest of wannabe infectious disease experts).Any idea if they're still doing full blown broad spectrum therapy for any SIRS+ patients pending cultures? I can see us running out of broad spectrum anti-microbial meds; in the middle of a viral pandemic I wonder if theyre considering changing guidelines.
Q: Are antibiotics effective in preventing or treating COVID-19?
A: No. Antibiotics do not work against viruses; they only work on bacterial infections. Antibiotics do not prevent or treat coronavirus disease (COVID-19), because COVID-19 is caused by a virus, not bacteria.
Do NOT extubate these patients early. They lose the positive pressure and derecruit.Have 1 confirmed case and few others suspected. Its a relentless virus. Relatively young guy here for 2 weeks was getting better. Has been on Remdesivir / Plaquenil now crashing again.
I am about to see my first case with high probability. What do you guys do when you get home? Do you quarantine yourself from your family? Assuming you wear full PPE
It has not
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I'm doing what I probably should have done from the beginning. Work clothes goes immediately in the washing machine, I immediately take a shower.
Ha... that's why wife's tactics. I'll admit... I don't go commando through the house.... just Sugar Ray.Scrub hamper in the garage. Walk inside naked and direct to shower. Family knows not to be between door and shower.
Managing the Critical COVID-19 Patient – SCCM Guidelines
COVID-19 is a global pandemic. This post focuses on management of the critically ill patient with COVID-19 by discussing the recently published Society of Critical Care Medicine and European Society of Intensive Care Medicine Guidelines.www.emdocs.net
Which part? Nothing jumps out at me, from bird's eye view. It's a pretty good guideline.Found this one a little too chicken-**** for my tastes
Which part? Nothing jumps out at me, from bird's eye view. It's a pretty good guideline.
I see it as a synopsis of best practices for the non-/weak intensivists who don't know them, and who feel the need for guidance.
Which part? Nothing jumps out at me, from bird's eye view. It's a pretty good guideline.
I see it as a synopsis of best practices for the non-/weak intensivists who don't know them, and who feel the need for guidance.
Thank you for your kind words. You probably know by now that the respect is mutual.As an aside, you are the guy literally dropping the MOST helpful stuff into this forum. Here and in the anesthesia forum.
I wasn't being critical of you, merely disappointed in SCCM
It takes zero stances on (most) of the hard questions, such as specific treatment
I'll concede your point that it's reasonable direction for a non-intensivist
Ok... which treatments are evidence based so far that would gain a strong recommendation? We're using hydroxychloroquine not because there's awesome evidence gaining it a strong recommendation, but because it's the only thing out there that we know of might work.
Anyone know if these death counts on the dashboards are including patients who chose palliative care/DNI?
Why do you ask? What difference does it make? Unless you think those patients are being left out?Anyone know if these death counts on the dashboards are including patients who chose palliative care/DNI?
Better to not make a rec when no or weak evidence to support a decision then to make a recommendation based on nothing... aka like strong rec for 30ml/kg fluid bolus in sepsis?then recommend weakly or don’t recommend
don’t sit on the fence - not helpful
It takes zero stances on (most) of the hard questions, such as specific treatment
I'll concede your point that it's reasonable direction for a non-intensivist
Better to not make a rec when no or weak evidence to support a decision then to make a recommendation based on nothing... aka like strong rec for 30ml/kg fluid bolus in sepsis?
steroid might be beneficial in patients suffering from immunnopathological cytokine storm
steroid may be indicated for other reasons
- Surviving Sepsis Campaign guidelines recommend steroid for intubated patients with ARDS.
- Currently, best evidence with COVID-19 comes from Wu et al 3/13/20.
- Retrospective, single-center study describing 201 patients with COVID-19 pneumonia.
- Among patients with ARDS, the use of methylprednisolone correlated with reduced mortality.
- Typically steroid is used in the sickest patients, so this will create a bias towards seeing worse outcomes in patients treated with steroid. A correlation in the opposite direction is surprising, suggesting that steroid could be causing benefit.
- Thus, it may be sensible to use low-dose corticosteroid in patients with ARDS and elevated inflammatory markers (e.g. C-reactive protein).
- Regimens used in China were typically methylprednisolone 40-80 mg IV daily for a course of 3-6 days, which seems reasonable (Shang et al. 2/29). Equivalent doses of dexamethasone (7-15 mg daily) could have an advantage of stimulating less fluid retention, since dexamethasone has less mineralocorticoid activity. Notably, this dose of steroid is consistent with doses used in the DEXA-ARDS trial.
- Authors generally agree that steroid should be used in patients with an independent indication for steroid, such as:
- Vasopressor-refractory shock
- Asthma or COPD exacerbation
If I may comment on steroids: the data is not clear. It has been used in Italy (and maybe China?) at doses of 1 mg/kg/day of methylprednisolone. You will have to find the references for that, many in interviews. And it makes sense to use it in a cytokine storm, when it's not the virus one is afraid of.
Since I belong to the church of Josh Farkas/Emcrit, this is one of my go-to pages: COVID-19 - EMCrit Project.
This is what he says:
Curiosity mostly.Why do you ask? What difference does it make? Unless you think those patients are being left out?
As long as palliative care is the patient's choice (versus "triage").Curiosity mostly.
Goes back to resource utilization. 100 palliative care deaths bothers me a lot less than 100 deaths where everything and the kitchen sink was thrown at it. Maybe I'm the only one that feels that way.
yes, sorry, should have been clearerAs long as palliative care is the patient's choice (versus "triage").
It's not an app, it's a shortcut to a website directory made for mobile. You can access it from any browser, even without installing the shortcut to your home screen: COVID.I haven't downloaded it myself, but this app is supposed to have all the updated resources re: covid and clinical care in 1 place:
It's not an app, it's a shortcut to a website directory made for mobile. You can access it from any browser, even without installing the shortcut to your home screen: COVID.