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Columbia for one. Their algo only uses it for moderately sick, >60 yrs old and with comorbidities. They admit it’s a shot in the dark.
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I’m not FFP, but there’s a paper on the use of Esmolol in sepsis.
Esmolol and Heart Rate Control in Septic Shock
To determine whether treating critically ill patients with severe septic shock with esmolol, a short-acting β-blocker, to reduce their heart rates, Morelli and coauthors conducted an open-label, randomized phase 2 study, involving 154 qualifying patients treated at a university hospital intensive...
jamanetwork.com
Unscrupulous clinicians extrapolate that to everybody and end up knocking patients off in the process.
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deleted171991
Obviously you're right. And I HATE knee-jerk stuff in the ICU (e.g. "if tachycardia give beta-blockers").
Unfortunately, people also tend to fall on the other side of the dogma, i.e. "NEVER treat sinus tachycardia with beta-blockers, because sinus tachycardia has a reason". Guess what? Sinus tachycardia also has consequences, as in worsening diastolic dysfunction +/- CAD, making the heart stiffer, increasing lung water, making lung disease even worse. The occasional success reported with esmolol + phenylephrine in sepsis may have a reason.
Especially since C19 patients are usually not hypotensive, it doesn't make sense (to me), to let them run away at 140 beats/min. I don't let ANY patient run at those speeds for a long-time. I start getting nervous around 110-115, especially in people with co-morbidities.
I am not that concerned about oxygen delivery in sepsis, more about peripheral perfusion, since we know that the body delivers about 5 times the amount of oxygen needed, and it's the mytochondria that get poisoned in a sepsis. I'd rather have a MAP of 50-60 with good urine output and warm extremities at 110/min on some esmolol, then a MAP of 65 with HR of 140 and/or clamped down from pressors.
To be clear, I only use beta-blockers for sinus tachycardia if the patient is running at 110-120+ all the time, and I cannot fix the cause (e.g. cytokines, NOT decreased SVR).
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Oxygen delivery is rarely a problem in sepsis, as evidenced by the fact that dobutamine, transfusion, and getting the svo2 up does nothing to improve outcomes. POCUS and or formal echo should be done routinely on septic patients throughout their hospital stay, IMO, just to make sure you’re not missing folks with cardiomyopathy, but most of the time the early to mid disease course will be characterized by an (unnecessarily) high CO / hyper dynamic state.
Some of the speculation and early data on BB is interesting, and I use it every now and then in sepsis because I am familiar with its effects in SIRS from burns.
Beta-blockers in sepsis: time to reconsider current constraints?
New insights into the mechanisms of action of beta-blockers, and the potential consequences for clinical practice, are continually evolving. Originally, th
academic.oup.com
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deleted171991
If the perfusion part looks to be under control (again, I value urine output and capillary refill more than MAP), yes. What I may do is "permissive hypotension" if that protects the heart or the peripheral perfusion. I don't like overworking the heart, except in young fit patients.
I work in an academic community (as in small, non-tertiary center) SICU, so I don't see as much sepsis as in fellowship (MICU) by far. But that's how I think about excessive tachycardia. I am a big fan of the middle way and moderation in everything, including heart rate, and a big enemy of perfection and of chasing numbers (that's what my surgeons do). I think excessive tachycardia and/or vasoconstriction may harm as much as excessive hypotension. I prefer a patient who looks well to good-looking numbers.
tl;dr: Severe tachycardia can be as bad as severe hypotension, and the treatment should not always be (more) pressor. The reason people did well in the esmolol + phenylephrine trials may have been that their hearts did well. Respect diastolic dysfunction and silent CAD, especially in hypertensive (i.e. LVH) patients (which the obese here most definitely were).
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SCCM put out their COVID-19 guideline. Hopefully it’s less trash than surviving sepsis but I doubt it.
Also interestingly
Also interestingly
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deleted171991
That's probably because "healthy" fat people have metabolic syndrome, with all the silent bad stuff, including chronic systemic inflammation, plus (and especially) decreased cardiorespiratory reserve with increased requirements.
Again, not saying that obesity (i.e. metabolic syndrome) is not a significant factor.
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Do you have more than one liners?
3.5k deaths in an overwhelmed health care system in an eldery population like northern Italy doesn't stike me as a huge tragedy.
What i'm more concerned about is what will happen when we get a real pandemic with millions of deaths.
Whoa. I’m not trolling you but these are not numbers, these are people. They still enjoyed reading, and socializing, and living their lives. It is a tragedy, and every one of these people that we either can’t save or can’t offer care to is going to be a tragedy.
I’m not saying that I’m going to cry over every death, because I’m not. But we owe it to ourselves and to our patients to bear witness to this event for what it really is.
A viral infection?
For the past 50y we have had a growing disconnection between life and death, probably in part because of the progress we have experienced in medical care.
I'm all for lowering infant and maternal mortality, vaccination etc etc but not accepting that 80+ y/o (or younger with comorbidities) die of a viral infections is strange to me.
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Heat wave in France in 2003 killed 15k in 15 days...
To clarify my position: people live and die everyday, yes this is a pandemic and will overwhelm resources in certain areas.
BUT due maybe to our understanding of infectious disease and confinement/distancing etc, or maybe due to the fact that this virus is not very agressive the numbers of deaths will be much less than previous pandemics.
I don't view this as preventable deaths: we are not yet able to control the life cycle and mutations of every virus or bacteria in existance so it's only logical to periodically experience widespread infections.
To clarify my position: people live and die everyday, yes this is a pandemic and will overwhelm resources in certain areas.
BUT due maybe to our understanding of infectious disease and confinement/distancing etc, or maybe due to the fact that this virus is not very agressive the numbers of deaths will be much less than previous pandemics.
I don't view this as preventable deaths: we are not yet able to control the life cycle and mutations of every virus or bacteria in existance so it's only logical to periodically experience widespread infections.
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I definitely was considering this.
John Hopkins physician; health-policy advisor:
1. How effective is quarantining?
2. Noncompetitive markets.......
1. How effective is quarantining?
2. Noncompetitive markets.......
I can’t remember if you are one of the posters I generally disagree with, but on this, I am with you. The demented, geriatrics, terminally ill, etc should not be sucking resources away from the people who can survive this crisis. Let’s not be “bleeding hearts” and try to save everyone. All of us will die. There is no shame or dishonor in choosing to focus our resources during a crisis on those who can make it and making those who can’t comfort care.
Has this been posted here yet? It says we are not yet doing enough to flatten the curve below level of overwhelmed healthcare system.
UMN, Mt. Sinai in Manhattan off the top of my head.
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deleted171991
Genius, eh? This isn't really a new idea. And there ain't no way he's getting 9 patients ventilated off one anesthesia machine. Much less 9 patients in the room.
PulmCrit - Splitting ventilators to provide titrated support to a large group of patients
COVID-19 might out-strip the number of mechanical ventilators available to us. This has led to interest in using a single ventilator to support
Dr. Oz on coronavirus shutdown: Entering a 'painful period' but we must give science a 'chance to win' | Fox News
Dr. Mehmet Oz on Friday urged Americans to socially distance themselves in order to help scientists make the effort to understand how to stop the coronavirus outbreak while it is contained.
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deleted171991
It's been done before. 😉
PulmCrit - Splitting ventilators to provide titrated support to a large group of patients
COVID-19 might out-strip the number of mechanical ventilators available to us. This has led to interest in using a single ventilator to support
Oz also said that the upcoming study from Aix Marseille Universite is going to change the perspective on how to treat the coronavirus. The study showed success using hydroxychloroquine, a drug commonly used to treat malaria and autoimmune diseases like lupus, as a treatment to cure the coronavirus.
Well if Dr OZ says it on national TV it must be true.
Well if Dr OZ says it on national TV it must be true.
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deleted171991
Oz? Oz??? He should be called "Dr. Alex Jones, DNP", after all the quackery he's promoted for money.
Once the TV doctors start stating we have medicine to treat Covid 19 the public will believe them. We all know the science behind this so called “cure” is sketchy at best. But, maybe the panic will die down a bit. FYI, I have Plaquenil and a Zpack ready because my chance of getting Covid 19 is at least 50/50 if not higher.
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deleted171991
If properly done, this is smart (pandemic-wise, not just electorally):
White House launches official Coronavirus news channel on the Roku Platform
White House launches official Coronavirus news channel on the Roku Platform
So you’re the reason drug is on shortage...
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
Are you guys running low on surgical masks in addition to n95 masks at your hospital ? We are which is sort of ridiculous.
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deleted131481
Need a biofresher. Viral load should play an important role on severity of illness, is that correct? First example is a PPE slipup on the mask while caring for a covid+ patient but assume some transmission vs a direct sneeze to the face by someone covid+. Presumably the 2nd case is much worse?
If that is true, I wonder if given the option we stagger staffing as much as possible to limit repeat exposure.
If that is true, I wonder if given the option we stagger staffing as much as possible to limit repeat exposure.
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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
I would not be surprised if the actual death rate turns out to be closer to the range of 0.2 - 0.1%. We have no idea how many are carriers and most of the infections appear to be subclinical or mild. I doubt this will be anywhere near as serious as the polio or Spanish flu epidemics our earlier generations lived through (with common sense measures and no media frenzy).
Check out this layman's briefing from a UChicago doc.
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deleted171991
Before that, it will be more like 9-10%, because of the hospitals being overwhelmed. That's happening RIGHT NOW in Italy. Expect the worst, people! Be mentally prepared to run out of beds, ventilators, PPEs, health, ?life.
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deleted171991
Just FYI, other countries pulled (hydroxy)chloroquine from their pharmacies the second the rumor started, only for hospital use. That's called proper response.
People are missing the point by saying 'the actual death rate will be close to 0.1%' if they are then taking those numbers and subsequently comparing it to the flu mortality.
How many people do you think get the flu each year who are never actually tested for it? Who knows what the 'actual' flu numbers are. That might mean the 'actual' flu numbers are closer to a mortality of 0.05%.
Even South Korea's numbers are over 1% and we are far behind them in being able to isolate cases and reduce the spread
Anyway you slice it, this is going to be worse than the flu until we have a proven vaccine/treatment. People are just grasping at straws here to make themselves feel better at night.
How many people do you think get the flu each year who are never actually tested for it? Who knows what the 'actual' flu numbers are. That might mean the 'actual' flu numbers are closer to a mortality of 0.05%.
Even South Korea's numbers are over 1% and we are far behind them in being able to isolate cases and reduce the spread
Anyway you slice it, this is going to be worse than the flu until we have a proven vaccine/treatment. People are just grasping at straws here to make themselves feel better at night.
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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...
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deleted171991
I hate mixing in politics on this thread, but, really, this is why Germany's numbers are so good:
It all boils down to national leadership. It's a national security (PREPAREDNESS) matter. It's too big for anybody else. Early quarantine, mass testing and tracking of cases is how one beats the disease.
Another, very possible, explanation is that they are still in the early days. There is no miracle treatment yet.
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We lament our piss poor national response right now, but what's going to happen in a month when people in NY can't find a hospital bed but OH or Iowa have managed to keep their numbers down?
Are we going to see locked borders between states? Mass movement from one place to another? The fact that we are still lacking a national response is going to make this a bloodbath.
Are we going to see locked borders between states? Mass movement from one place to another? The fact that we are still lacking a national response is going to make this a bloodbath.
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deleted171991
It's also a rich area, with many older people (young people can't afford expensive cities). And a very touristic area. Some of the pictures from the weeks before the tsunami looked like NYC's 5th Ave on a beautiful summer day: PACKED, so very high transmission probably.
Even with PERFECT quarantine and control, this virus takes another 10-15 days just to peak, due to the already infected cases, so it keeps overwhelming the system for weeks to come. And the Italians are still amateurs at quarantine, the Chinese say, hence the thousands of new cases and almost thousand deaths EVERY DAY.
And don't blame their healthcare. Lombardy's hospitals are on par with ours. If anything, socialized healthcare and lack of defensive medicine allows them to do the right thing for the patients, and not worry about getting paid or sued.
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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
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If anyone has actually read the French study on hydroxychloroquine and azithromycin, you would see there are major holes in it.
It was not randomized or blinded.
Only 36 patients, 20 in the hydroxychloroquine group and 16 in the control group.
Their graphs of miraculous negative pcrs in the experimental group fail to mention that there were an additional 6 pts initially in the hydroxychloroquine group, 3 who transfered to the ICU, 1 who died who tested negative for pcr the day before death. These were excluded from their outcomes.
No patients in the control group died or went to the icu.
They don't mention whether patents were matched for comorbidities and don't include a detailed evaluation of patent status at day 0
Don't include all cause mortality at day 14-21. Important as everything we've read states most who die, do so in two to three weeks on average.
Only include viral load at day six.
Mortality in the control group could very well be better than in the experimental group regardlesss of viral load.
This is why it's irresponsible for our president to be announcing the use of this drug so prematurely to the whole world.
It was not randomized or blinded.
Only 36 patients, 20 in the hydroxychloroquine group and 16 in the control group.
Their graphs of miraculous negative pcrs in the experimental group fail to mention that there were an additional 6 pts initially in the hydroxychloroquine group, 3 who transfered to the ICU, 1 who died who tested negative for pcr the day before death. These were excluded from their outcomes.
No patients in the control group died or went to the icu.
They don't mention whether patents were matched for comorbidities and don't include a detailed evaluation of patent status at day 0
Don't include all cause mortality at day 14-21. Important as everything we've read states most who die, do so in two to three weeks on average.
Only include viral load at day six.
Mortality in the control group could very well be better than in the experimental group regardlesss of viral load.
This is why it's irresponsible for our president to be announcing the use of this drug so prematurely to the whole world.
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