COVID-19

[NontradICUdoc]

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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

 

[Hernandez]

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'm dressing bare below elbows at work. When I get home, I Walk in throw my cloths in washer and hop in shower Before I interact with the family. I'm going to start changing into hospital scrubs and back before I leave work and continue the strip/shower routine. if/when ppe becomes an issue, I'll probably send the family to my parents or re-arrange and stay isolated in on or the kids rooms when I move them in with a sibling.

I've been debating making a low percentage bleach solution to keep in the shower, mainly for my neck and arms.

 

[deleted171991]

Covid-19 protocols, from the Alfred ICU in Australia:

ICU Management of COVID19 | Alfred ICU guideline - INTENSIVE

This guideline describes ICU Management of COVID19 at the Alfred Hospital.

intensiveblog.com

COVID-19 precautions during Code Blue on the wards - Alfred ICU guideline - INTENSIVE

This guideline describes COVID-19 precautions during Code Blue on the wards at the Alfred Hospital.

intensiveblog.com

ICU patient allocation with suspected or confirmed COVID-19 | Alfred ICU guideline - INTENSIVE

This guideline describes ICU patient allocation with suspected or confirmed COVID-19 at the Alfred Hospital.

intensiveblog.com

Sterile Procedure Workflow in a COVID-19 Cubicle | Alfred ICU Guideline - INTENSIVE

This guideline describes the sterile procedure workflow in a COVID-19 cubcle at the Alfred ICU.

intensiveblog.com

 

[deleted171991]

Useful Dashboards for Tracking the Coronavirus

Track the Coronavirus around the world in real time with these dashboards. These dashboards aggregate data and create maps and visuals that various information about the Coronavirus, where it's been, current statistics, where it's spreading, and its epidemiology and transmission. There are many...

www.techsupportalert.com

 

[deleted171991]

interesting. I keep seeing “early intubation” a lot but this guy says their experience with CPAP was very good.

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.

 

[deleted171991]

Global MediXchange for Combating COVID-19(GMCC)

Global MediXchange for Combating COVID-19 is a medical exchange program to promote valubale experience sharing and communication in combating the global outbreak of COVID-19.

covid-19.alibabacloud.com

Sponsored by Alibaba, China's Amazon.

Example of resource:
Handbook of COVID-19 Prevention and Treatment (68 pages) - Compressed Version (small screens)
Handbook of COVID-19 Prevention and Treatment (68 pages) - Standard Version

 

[Modeselektor]

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 ****.

 

[deleted171991]

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 ****.

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).

But you can't undo what the immunosuppression of an A1c over 11 has done to him. What uncontrolled diabetics need to do right now is start keto diet (and/or fasting) with supervision. Insulin stimulates epinephrine release (immune depressant), hence these people should not be on tube feeds and other sugary crap (e.g. "diabetic" hospital food) that increase their insulin requirements even more.

 

[SurfingDoctor]

Desperate times call for desperate measures. Clever though.

 

[BIGphysician]

Havent logged into SDN for ALONG time, was looking for some type of outlet for this convo. Anyone consider Europe having a mutated virus that's more virulent? Usually when viruses mutate they get less virulent but if you look at the numbers per 1 million, that northern Italy and Switzerland case number is spreading like fire that's becoming outlier level.

Best website i've found: Coronavirus Update (Live): 304,217 Cases and 12,983 Deaths from COVID-19 Virus Outbreak - Worldometer

Corona Virus spike protein which facilitate viral entry, mutation: RBD mutations from circulating SARS-CoV-2 strains enhance the structure stability and infectivity of the spike protein

 

[BIGphysician]

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 articles

mandrillapp.com

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.

 

[deleted171991]

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.

Who are "they"? I am pretty sure it's not the IDSA (I don't care about the rest of wannabe infectious disease experts).

The Covid-19 initial labs are pretty suggestive -> normal WBC and lymphopenia. But it's a very good question. I wouldn't give more than 24 hours of antibiotics to these patients, if suggestive of Covid-19, absent purulent sputum or ARDS. The CDC should come out and say it.

Gods bless the FDA:

COVID-19 Frequently Asked Questions

COVID-19 Questions and Answers for a general public or consumer audience.

www.fda.gov

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.

 

[Nephro critical care]

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.

 

[deleted171991]

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.

Do NOT extubate these patients early. They lose the positive pressure and derecruit.

 

[Siggy]

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'm doing what I probably should have done from the beginning. Work clothes goes immediately in the washing machine, I immediately take a shower.

 

[TooMuchResearch]

I've seen ads for Pinnacle Biolabs IgM/IgG testing but only available in EU/GB.

It has not


Sent from my iPad using Tapatalk

 

[TooMuchResearch]

Scrub hamper in the garage. Walk inside naked and direct to shower. Family knows not to be between door and shower.

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.

 

[SurfingDoctor]

Scrub hamper in the garage. Walk inside naked and direct to shower. Family knows not to be between door and shower.

Ha... that's why wife's tactics. I'll admit... I don't go commando through the house.... just Sugar Ray.

 

[deleted171991]

Managing the Critical COVID-19 Patient – SCCM Guidelines - emDocs

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

A plea from doctors in Italy: To avoid Covid-19 disaster, treat more patients at home

Physicians at the epicenter of Italy’s #Covid19 outbreak warned that medical practice may need to be turned on its head — with care delivered to many #coronavirus patients at home.

www.statnews.com

 

[CCM-MD]

Maybe off topic, but I think it relates: how is everyone doing from a psychological standpoint? I like to think of myself as a strong person but a lot of this is catching up to me. I only have one confirmed and a few suspected so far but the amount of information, worrying about my parents and other family is really catching up to me.

How is everyone doing?

 

[jdh71]

Managing the Critical COVID-19 Patient – SCCM Guidelines - emDocs

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

Found this one a little too chicken-**** for my tastes

 

[deleted171991]

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.

 

[jdh71]

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.

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

 

[jdh71]

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.

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

 

[deleted171991]

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

Thank you for your kind words. You probably know by now that the respect is mutual.

I didn't take it personally, I just wasn't sure what I had missed.

 

[Siggy]

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.

 

[jdh71]

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.

then recommend weakly or don’t recommend

don’t sit on the fence - not helpful

 

[BigRedBeta]

Anyone know if these death counts on the dashboards are including patients who chose palliative care/DNI?

 

[Hernandez]

Anyone know if these death counts on the dashboards are including patients who chose palliative care/DNI?

I believe so based off local numbers

 

[chocomorsel]

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?

 

[deleted171991]

Ferguson et al, 2020 - Imperial College (UK) COVID-19 Response Team Report | INTENSIVE Review - INTENSIVE

COVID-19 Alfred ICU Summary: Ferguson et al, 2020 - Imperial College (UK) COVID-19 Response Team Report

intensiveblog.com

 

[MoMoGesiologist]

then recommend weakly or don’t recommend

don’t sit on the fence - not helpful

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?

 

[MoMoGesiologist]

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

What’s your opinion on the steroids rec? From my understanding, quite some evidence viral PNAs may be worsened by steroids. Here, it’s being weakly recommending if ARDS

 

[deleted171991]

COVID-19 resources - First10EM

The COVID-19 resources that I have found most useful: Guidelines, FOAMed, maps, education, and evidence based medicine

first10em.com

COVID Resuscitation Principles - First10EM

The COVID resuscitation principles that we created for our department - airway management and cardiac arrest keeping both patient and provider safe.

first10em.com

COVID airway management: SAS consensus statement - First10EM

A look at recomended practice for COVID airway management - guidance from the Safe Airway Society.

first10em.com

 

[jdh71]

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?

we have SOME data on directed treatments though, hiding behind not making a choice in this case is a chicken **** way of NOT recommending.

The steroid recommendations are consistent with current available data and immunological pathophysiology.

 

[deleted171991]

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:

steroid might be beneficial in patients suffering from immunnopathological cytokine storm

• 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.

steroid may be indicated for other reasons

• 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

 

[jdh71]

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:

I might humbly suggest that we ALL should remember we are all going to be bringing certain confirmation bias to our approach with these patients and it will likely be long over before we have the kind of data we all like to have and see and that directs the best care.

As critical care physicians we see tasked all day every day whether it’s these patients or not to wade into the deep and dark waters with basically no further scientific evidence than our knowledge of physiology, pathophysiology, and first principles. We have to think around corners and out of boxes. We are the physicians they everyone else dumps their disasters on because the case has become hard, complicated, and no one else is willing to take the time to figure out what is going on and to come up with a plan. So. We have to use what is currently available. The currently available best data which can be criticized as much as one wants, does show a positive signal for steroids in Covid19 ARDS.

Back to confirmation bias then, as a pulmonologist who uses steroids all the time and sometimes for months on end I am very comfortable and facile with their use. I don’t think they are poison but rather a weapon in the arsenal cautiously deployed for the potential collateral damage, especially in long term use by people not paying close enough attention. I see steroids generally positively. If one sees steroids as generally negative and only used in situations dictated by the RTCs in appropriate settings then one may not find current data very convincing.

With that said, I wouldn’t say the data isn’t clear. We have a clear positive signal. I think it’s fair to say not as bright or robust a positive signal that one would like.

 

[Nephro critical care]

Has anybody got a patient off the vent successfully. I have one who seemed to be turning the corner after remdisivir and Plaquenil. But not extubated. Now sats are crashing again.

 

[Nephro critical care]

If we cant get a pt off the vent then I will discourage all pts with comorbidity above the age of 65 from getting intubated.

 

[jdh71]

Currently have two patients in the ICU.

One 60s, on PEEP, and Fio2 of 0.4, much more "classic"

The other is more interesting in that this patient is 20s, very few respiratory complaints, not on oxygen, GI symptoms predominant and fever, weak as a kitten, syncope, and small pericardial effusion - too sick to go home, and smells like could crump quickly so since we do have the beds right now, watching

 

[deleted171991]

COVID19: SARS-CoV-2 Transmission and Masks – FOAMcast

foamcast.org

 

[BigRedBeta]

Why do you ask? What difference does it make? Unless you think those patients are being left out?

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.

 

[deleted171991]

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.

As long as palliative care is the patient's choice (versus "triage").

 

[BigRedBeta]

As long as palliative care is the patient's choice (versus "triage").

yes, sorry, should have been clearer
But should it get to that point, might also be useful to know triage numbers as well.

 

[AMEHigh]

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:

老男人A片免费视频_老老熟妇XxXXHD_老汉永久免费视频福利草民

老男人A片免费视频_老老熟妇XxXXHD_老汉永久免费视频福利草民

covid19medapp.com

 

[deleted171991]

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:

老男人A片免费视频_老老熟妇XxXXHD_老汉永久免费视频福利草民

老男人A片免费视频_老老熟妇XxXXHD_老汉永久免费视频福利草民

covid19medapp.com

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.

 

[deleted171991]

CDC says coronavirus RNA found in Princess Cruise ship cabins up to 17 days after passengers left

Traces of the coronavirus were found up to 17 days after passengers disembarked the Diamond Princess cruise ship, surviving far longer on surfaces than previous research has shown, according to new data published Monday by the Centers for Disease Control and Prevention.

www.cnbc.com

 

[Modeselektor]

 

[AMEHigh]

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.

Yes sorry for the incorrect wording. Thought it might be helpful for some.

 

[deleted171991]