What Do I Need To Know About SARS-CoV-2 Hospitalizations?

[WilcoWorld]

1 - If you can avoid intubation, please do. High Flow Nasal Cannula probably leads to better hospital courses.
2 - Steroids, maybe???
3 - Being in the hospital isn't fun. When you've got 'The Rona' it's worse.
4 - Once we're talking about prone ventilation, your family should be discussing goals of care.

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[WilcoWorld]

Let's try this again.

@Angry Birds

 

[chocomorsel]

Love it.
Can we clarify the prone ventilation while intubation versus just prone breathing in a spontaneously breathing patient?
IMO by the time patients come to the ER in dire straights talking about I can't breathe, it's too late for steroids and plasma.
However, I don't see the ones who do well on the floors so maybe?. Just the ones who come to the unit to unfortunately die.

 

[Renaissance Man]

In the ED when patients first arrive and are febrile & hypoxic and you have the bilateral infiltrates on CXR are you giving an empiric dose of antibiotics? I usually give some CAP coverage with 6 mg of Decadron if they are requiring oxygen, although I am not sure about prevalence of superimposed bacterial pneumonia.

I also tend to run them dry and consider a dose of Lasix if they are going to be with me for a few hours.

 

[chocomorsel]

In the ED when patients first arrive and are febrile & hypoxic and you have the bilateral infiltrates on CXR are you giving an empiric dose of antibiotics? I usually give some CAP coverage with 6 mg of Decadron if they are requiring oxygen, although I am not sure about prevalence of superimposed bacterial pneumonia.

I also tend to run them dry and consider a dose of Lasix if they are going to be with me for a few hours.

That's what is happening at the hospitals I staff as well. Can't say for sure if it's helping or hurting.
Who do you decide to give Lasix to? I often wonder if we run them too dry at first. Because of their high propensity to go into AKI. But obviously if they don't need fluids and are not hypotensive, dry is right.

 

[southerndoc]

In the ED when patients first arrive and are febrile & hypoxic and you have the bilateral infiltrates on CXR are you giving an empiric dose of antibiotics? I usually give some CAP coverage with 6 mg of Decadron if they are requiring oxygen, although I am not sure about prevalence of superimposed bacterial pneumonia.

I also tend to run them dry and consider a dose of Lasix if they are going to be with me for a few hours.

This is what we're doing. Avoiding fluids (even if tachycardic) unless they look dry from vomiting and such. High-flow nasal cannula for hypoxemic, remdesivir if symptoms <7 days, dexamethasone 6 mg daily for 10 days if O2 dependent, and prone them liberally. We avoid intubation at all costs now. Basically if they're an impending respiratory arrest, then we tube.

 

[Renaissance Man]

That's what is happening at the hospitals I staff as well. Can't say for sure if it's helping or hurting.
Who do you decide to give Lasix to? I often wonder if we run them too dry at first. Because of their high propensity to go into AKI. But obviously if they don't need fluids and are not hypotensive, dry is right.

Good question, I don't have a hard and fast rule. The sicker folks tend to have some aspect of cardiac dysfunction and hypotension seems to be exceedingly rare. I will wait for kidney function too.

 

[AMEHigh]

This is what we're doing. Avoiding fluids (even if tachycardic) unless they look dry from vomiting and such. High-flow nasal cannula for hypoxemic, remdesivir if symptoms <7 days, dexamethasone 6 mg daily for 10 days if O2 dependent, and prone them liberally. We avoid intubation at all costs now. Basically if they're an impending respiratory arrest, then we tube.

Does anyone know if we're seeing better mortality rates because of this?

 

[chocomorsel]

Does anyone know if we're seeing better mortality rates because of this?

Anecdotally, speaking strictly from the ICU perspective, the answer is hell no!!! Mortality in the ICU is still close to 100%.
Hopefully someone who works the floors or has read more than me can also on this.

 

[southerndoc]

Are folks treating symptomatic patients discharged from the ED, or non-critically ill hospitalized patients, with Dexamethasone? If treating, what dose/duration?

I’ve found myself treating a lot of outpatient managed, positive or presumed positive patients, with a single dose of Dexamethasone 10 mg PO prior to discharge. I haven’t been doing a longer duration. Dexamethasone dosing in general seems nebulous and random. Any dosing evidence to support 6 mg, 10 mg, weight based vs. other dosing? If an asthmatic presents in mild exacerbation (with history also suspicious for SARS-CoV-2), but improves with treatment, then I’ll usually do a short course of Presnisone instead of Dexamethasone.

The RECOVERY trial published from the UK was 6 mg daily for 10 days for patients requiring oxygen or ventilation. I think mortality was reduced by a fifth for those requiring oxygen and reduced by a third for those requiring ventilation.

Patients not requiring oxygen/ventilation did worse (although not statistically significant) when they got dexamethasone. So no, I don't discharge patients on dexamethasone. Symptomatic treatment only (except antibiotics if they also have an infiltrate on chest x-ray).

 

[southerndoc]

Forgot to mention that we are also using convalescent plasma from Mayo for some COVID patients (was used on a hypoxemic pregnant patient recently with good outcome).

 

[GeneralVeers]

Definitely doing dexamethasone on any patients with hypoxemia. We are trying high-flow nasal cannula as much as possible. With regards to proning and other interventions, that's up to the critical care team.

The problem we are having, is that a lot of these patients are getting admitted to Intermediate Care with some mild hypoxemia. At 7PM when the covering NP/PA comes on for the hospitalist, they immediately call down to us: "OMG this patient needs intubation!". They don't really require intubation, but the inpatient coverage is so bad at night that they don't know what to do. I calmly ask them to consult critical care first, then call me back if needed.

 

[Rekt]

Are folks treating symptomatic patients discharged from the ED, or non-critically ill hospitalized patients, with Dexamethasone? If treating, what dose/duration?

I’ve found myself treating a lot of outpatient managed, positive or presumed positive patients, with a single dose of Dexamethasone 10 mg PO prior to discharge. I haven’t been doing a longer duration. Dexamethasone dosing in general seems nebulous and random. Any dosing evidence to support 6 mg, 10 mg, weight based vs. other dosing? If an asthmatic presents in mild exacerbation (with history also suspicious for SARS-CoV-2), but improves with treatment, then I’ll usually do a short course of Presnisone instead of Dexamethasone.

Definitely not. Unless they have a new oxygen requirement or hypoxemia, then hold on dex. Theoretically can increase viral replication early on. Worried well gets told to take Tylenol, Ibuprofen, Zinc and Vitamin D with their discharge paperwork.

 

[WilcoWorld]

Does anyone know if we're seeing better mortality rates because of this?

I'm not sure about mortality but morbidity is almost certainly lower when intubation is avoided.

Seems like the burden of proof should be on showing that mortality improves with intubation, no?

 

[GeneralVeers]

I'm not sure if the mortality is lower, but I strongly suspect that the morbidity is lower when intubation is avoided.

Seems like the burden of proof should be on showing that mortality improves with intubation, no?

Would be interesting to see if never intubating these COVID patients results in slightly less mortality than mechanical ventilation. I doubt it's a study that could be done due to ethical issues.

 

[Siggy]

Would be interesting to see if never intubating these COVID patients results in slightly less mortality than mechanical ventilation. I doubt it's a study that could be done due to ethical issues.

At this point we're only intubating if the SpO2 is <88 on 100% Bipap with 20 over 10 or actively in respiratory distress. Some end up recovering, some move on to intubation.

 

[southerndoc]

At this point we're only intubating if the SpO2 is <88 on 100% Bipap with 20 over 10 or actively in respiratory distress. Some end up recovering, some move on to intubation.

This is basically what we're following too... although I think some of the intensivists are going to 86%.

 

[Siggy]

This is basically what we're following too... although I think some of the intensivists are going to 86%.

I finished up fellowship in June and I've quipped that if I would have suggested, "hey, let's just sit here and watch" with half of these patients, my attending would have Gibbs slapped me.

 

[Zebra Hunter]

I've responded to numerous COVID floor codes now where the patient coded due to the team waiting way too long to intubate (consistent pulse ox readings below 90% for hours while maxed out on non-invasive ventilation). I think the pendulum has fallen way too far to the other side. We went from intubate everyone who needs more than 6L NC, to "you're going to murder them if you intubate them" which are both preposterous extremes which I have been trying to push back against since day 1. Our intensivists currently won't intubate COVID patients unless their O2 sat falls below 85% which is way too low (not sure how they decided on that number). We already know from the recent LOCO2 trial that conservative oxygen therapy (maintaining O2 sat between 88-92%) in ARDS patients is unlikely to be helpful and very likely detrimental. LOCO2 was stopped early due to safety concerns as there was an absolute mortality increase of 8% in the conservative oxygen group compared to the liberal (O2 sat >/= 96%), although was not technically statistically significant. Some might think this flies in the face of the OXYGEN-ICU trial, however, it is important to note that although they claimed their treatment arms were "conservative" vs "conventional", it really should have been "conventional" vs "induced hyperoxia" groups given that the "conservative" group maintained sats between 94-98% and the "conventional" was 97-100%.

I've been a strong proponent of doing the same things we have been doing well for decades, and don't let non-randomized, observational data or "expert consensus" change your practice with regards to COVID. Give plenty of fluids if the patient is clearly dehydrated, as many COVID patients will be due to diarrhea and vomiting which is prevalent in many with it. Give them dexamethasone if they are hypoxic. Intubate them if NIV can't maintain their O2 sat above 90% (my personal lower limit), just like most of y'all were doing before for flu or pneumonia patients. And for heaven's sake, follow ARDSnet protocol for mechanically ventilated patients. Don't withhold PEEP because you saw some random doc on the internet claim that he thinks these are basically HAPE patients, or because some FOAMed guy is putting out nonsense about H and L phenotypes of COVID.

...Sorry about the rant

 

[Dr Mantis Toboggan]

I've responded to numerous COVID floor codes now where the patient coded due to the team waiting way too long to intubate (consistent pulse ox readings below 90% for hours while maxed out on non-invasive ventilation). I think the pendulum has fallen way too far to the other side. We went from intubate everyone who needs more than 6L NC, to "you're going to murder them if you intubate them" which are both preposterous extremes which I have been trying to push back against since day 1. Our intensivists currently won't intubate COVID patients unless their O2 sat falls below 85% which is way too low (not sure how they decided on that number). We already know from the recent LOCO2 trial that conservative oxygen therapy (maintaining O2 sat between 88-92%) in ARDS patients is unlikely to be helpful and very likely detrimental. LOCO2 was stopped early due to safety concerns as there was an absolute mortality increase of 8% in the conservative oxygen group compared to the liberal (O2 sat >/= 96%), although was not technically statistically significant. Some might think this flies in the face of the OXYGEN-ICU trial, however, it is important to note that although they claimed their treatment arms were "conservative" vs "conventional", it really should have been "conventional" vs "induced hyperoxia" groups given that the "conservative" group maintained sats between 94-98% and the "conventional" was 97-100%.

I've been a strong proponent of doing the same things we have been doing well for decades, and don't let non-randomized, observational data or "expert consensus" change your practice with regards to COVID. Give plenty of fluids if the patient is clearly dehydrated, as many COVID patients will be due to diarrhea and vomiting which is prevalent in many with it. Give them dexamethasone if they are hypoxic. Intubate them if NIV can't maintain their O2 sat above 90% (my personal lower limit), just like most of y'all were doing before for flu or pneumonia patients. And for heaven's sake, follow ARDSnet protocol for mechanically ventilated patients. Don't withhold PEEP because you saw some random doc on the internet claim that he thinks these are basically HAPE patients, or because some FOAMed guy is putting out nonsense about H and L phenotypes of COVID.

...Sorry about the rant

Couldn’t agree more. It is definitely a new disease with some weird wrinkles, but we still have to stick with the fundamentals of critical care in my opinion.

 

[WilcoWorld]

I've responded to numerous COVID floor codes now where the patient coded due to the team waiting way too long to intubate (consistent pulse ox readings below 90% for hours while maxed out on non-invasive ventilation). I think the pendulum has fallen way too far to the other side. We went from intubate everyone who needs more than 6L NC, to "you're going to murder them if you intubate them" which are both preposterous extremes which I have been trying to push back against since day 1. Our intensivists currently won't intubate COVID patients unless their O2 sat falls below 85% which is way too low (not sure how they decided on that number). We already know from the recent LOCO2 trial that conservative oxygen therapy (maintaining O2 sat between 88-92%) in ARDS patients is unlikely to be helpful and very likely detrimental. LOCO2 was stopped early due to safety concerns as there was an absolute mortality increase of 8% in the conservative oxygen group compared to the liberal (O2 sat >/= 96%), although was not technically statistically significant. Some might think this flies in the face of the OXYGEN-ICU trial, however, it is important to note that although they claimed their treatment arms were "conservative" vs "conventional", it really should have been "conventional" vs "induced hyperoxia" groups given that the "conservative" group maintained sats between 94-98% and the "conventional" was 97-100%.

I've been a strong proponent of doing the same things we have been doing well for decades, and don't let non-randomized, observational data or "expert consensus" change your practice with regards to COVID. Give plenty of fluids if the patient is clearly dehydrated, as many COVID patients will be due to diarrhea and vomiting which is prevalent in many with it. Give them dexamethasone if they are hypoxic. Intubate them if NIV can't maintain their O2 sat above 90% (my personal lower limit), just like most of y'all were doing before for flu or pneumonia patients. And for heaven's sake, follow ARDSnet protocol for mechanically ventilated patients. Don't withhold PEEP because you saw some random doc on the internet claim that he thinks these are basically HAPE patients, or because some FOAMed guy is putting out nonsense about H and L phenotypes of COVID.

...Sorry about the rant

Couldn’t agree more. It is definitely a new disease with some weird wrinkles, but we still have to stick with the fundamentals of critical care in my opinion.

Agreed, in the absence of evidence, theory and practical experience are good substitutes.

Re: fundamentals of critical care - it does sound like the management @Zebra Hunter is describing has taken the tolerance of hypoxia to an extreme. It's not described in your post, but I wonder if these docs are failing to actually LOOK at the patients and do a full clinical assessment - instead just looking at the pulse ox. If I have a patient with a sat of 88% on 4L/min via NV who's speaking in full sentences and asking for a dinner menu - I'm not gonna intubate that guy. Show me a patient who's satting 91% on 6l/min by maintaining that 91% with 26 times/minute while only speaking one word at a time and I'm gonna put that guy on HFNC, bring my airway setup to the bedside and watch real close, cuz if he doesn't turn around I'm gonna tube him.

 

[chocomorsel]

Some of these patients are also very afraid of buying the tube because they have heard it’s a death sentence. Let’s not forget that.
And then when they finally tire out, they are on the brink.
At my last place, they weren’t intubating most patients with a sat in the mid 80s. Not my shop so I don’t push back.
But again, saw a few very scared patients who didn’t want to be tubed.

 

[WheezyBaby]

Anecdotally, speaking strictly from the ICU perspective, the answer is hell no!!! Mortality in the ICU is still close to 100%.
Hopefully someone who works the floors or has read more than me can also on this.

This has not been my institution's experience. I know we're writing up the data, and it doesn't appear it's published yet, but our ICU survival was >50% (don't remember the exact number, believe mortality was somewhere in the 20's to 40's). We haven't been doing anything sexy that I'm aware of, and treatments have run the gamut of HCQ to toci / plasma / remdesevir to decadron and from tube at 6L to avoid tube.

 

[WilcoWorld]

Anecdotally, speaking strictly from the ICU perspective, the answer is hell no!!! Mortality in the ICU is still close to 100%.
Hopefully someone who works the floors or has read more than me can also on this.

This has not been my institution's experience. I know we're writing up the data, and it doesn't appear it's published yet, but our ICU survival was >50% (don't remember the exact number, believe mortality was somewhere in the 20's to 40's). We haven't been doing anything sexy that I'm aware of, and treatments have run the gamut of HCQ to toci / plasma / remdesevir to decadron and from tube at 6L to avoid tube.

I'm speculating, but I wonder if there's a selection difference? Could it be that you have to be much more sick to get admitted to @chocomorsel's ICU?

I know some hospitals will require anyone on over 6L/min to go to an ICU while others will run BiPap on the floor.

In any case @WheezyBaby - you should definitely publish those findings.

 

[Zebra Hunter]

I'm speculating, but I wonder if there's a selection difference? Could it be that you have to be much more sick to get admitted to @chocomorsel's ICU?

I know some hospitals will require anyone on over 6L/min to go to an ICU while others will run BiPap on the floor.

In any case @WheezyBaby - you should definitely publish those findings.

Eh, mechanically ventilated mortality rate for COVID outside of NYC or China has been somewhere around 50% or lower in most published literature. No way anyone is seeing 100% mortality in their patient cohort. Our large hospital system has a mortality rate of around 40% for mechanically ventilated patients per our CMOs most recent update.

 

[WheezyBaby]

I'm speculating, but I wonder if there's a selection difference? Could it be that you have to be much more sick to get admitted to @chocomorsel's ICU?

I know some hospitals will require anyone on over 6L/min to go to an ICU while others will run BiPap on the floor.

In any case @WheezyBaby - you should definitely publish those findings.

It's definitely being written up, but I'm not one of the authors . I think we allow a reasonable acuity level before mandating ICU level care; exact rules vary by hospital. HFNC permitted universally. Acute BiPAP depends on facility and policy changed somewhat during COVID due to volume; pre-COVID was either ICU-only or non-ICU + ICU consult. Due to COVID volume, there was a period of time where acute BiPAP wasn't a strict indication for ICU admit or consult. Can do continuous albuterol, non-pressor vasoactive gtts, insulin gtt, etc all non-ICU based

Edit:it's been published, mortality was in the 20's for our MV population

 

[chocomorsel]

Eh, mechanically ventilated mortality rate for COVID outside of NYC or China has been somewhere around 50% or lower in most published literature. No way anyone is seeing 100% mortality in their patient cohort. Our large hospital system has a mortality rate of around 40% for mechanically ventilated patients per our CMOs most recent update.

Who says these hospitals that are seeing such high death rates are publishing their cases or advertising it?
Just because you haven't read it, or it's not happening in your hospitals means it's a lie?
So your "eh", dismissive attitude, is someone else's nightmarish reality.
Good for you to have such good success rates because I don't exactly want most of my Covid patients to die. But they do.
Well, I guess I should have been more specific. I am seeing close to 100% mortality in my Hospital ICUs once they are intubated. Maybe we are doing things all backwards or something. Or maybe, we have a very sick patient population with lots of morbidity to begin with.

 

[chocomorsel]

This has not been my institution's experience. I know we're writing up the data, and it doesn't appear it's published yet, but our ICU survival was >50% (don't remember the exact number, believe mortality was somewhere in the 20's to 40's). We haven't been doing anything sexy that I'm aware of, and treatments have run the gamut of HCQ to toci / plasma / remdesevir to decadron and from tube at 6L to avoid tube.

I suspect it's got something to do with the Cohort of patients you work with. I live in a largely Hispanic area and work in a mostly Hispanic part of the state. The Hispanic patient population is seeing a lot of death from this illness. People in their 50's-60's.
I suspect genetics and comorbidities. Even when I was up in a town in NY that was not heavily Hispanic, we had a large selection of that patient population in the ICU doing of course poorly.

 

[chocomorsel]

It's definitely being written up, but I'm not one of the authors . I think we allow a reasonable acuity level before mandating ICU level care; exact rules vary by hospital. HFNC permitted universally. Acute BiPAP depends on facility and policy changed somewhat during COVID due to volume; pre-COVID was either ICU-only or non-ICU + ICU consult. Due to COVID volume, there was a period of time where acute BiPAP wasn't a strict indication for ICU admit or consult. Can do continuous albuterol, non-pressor vasoactive gtts, insulin gtt, etc all non-ICU based

Edit:it's been published, mortality was in the 20's for our MV population

What part of the US is this may I ask? What's your patient population? You got a link to this study?

 

[AlmostAnMD]

My ED doesn't allow me to do NIV in COVID patients Admin says it will aerosolize, yadda yadda yadda

So I can do NC or just go straight to tube. Or admit to ICU. But no bipap. Dumb.

 

[WilcoWorld]

My ED doesn't allow me to do NIV in COVID patients Admin says it will aerosolize, yadda yadda yadda

So I can do NC or just go straight to tube. Or admit to ICU. But no bipap. Dumb.

You can't do optiflow? Seems like your admin is skipping a potentially useful step.

We aren't using BiPap for COVID either, but it's supplemental O2 --> supplemental O2 + self-proning --> optiflow --> ETT. Anecdotally, we have a lot of patients who get to optiflow, then get better, and avoid the vent.

 

[chocomorsel]

My ED doesn't allow me to do NIV in COVID patients Admin says it will aerosolize, yadda yadda yadda

So I can do NC or just go straight to tube. Or admit to ICU. But no bipap. Dumb.

Hope you don't run out of ICU beds. Hopefully they aren't buying the tube too early either.

 

[WheezyBaby]

What part of the US is this may I ask? What's your patient population? You got a link to this study?

I'll PM you

 

[GeneralVeers]

You can't do optiflow? Seems like your admin is skipping a potentially useful step.

We aren't using BiPap for COVID either, but it's supplemental O2 --> supplemental O2 + self-proning --> optiflow --> ETT. Anecdotally, we have a lot of patients who get to optiflow, then get better, and avoid the vent.

We've been doing a lot of this too. The high flow O2 for a day or two hopefully buys the lungs enough time to recover from the cytokine storm in order to avoid intubation. Definitely have been doing a lot fewer COVID floor intubations in the last 2 months.

 

[turkeyjerky]

Are any if you seeing any bronchospasm in ‘rona cases? I was initially quite worried about it causing asthma exacerbations and the ensuing treatment dilemmas, but I really haven’t seen any of this. Just wondering whether I was alone or not.

 

[thegenius]

Are any if you seeing any bronchospasm in ‘rona cases? I was initially quite worried about it causing asthma exacerbations and the ensuing treatment dilemmas, but I really haven’t seen any of this. Just wondering whether I was alone or not.

Nope.....

basically most people with symptomatic 'RONA just looks fairly comfortable and it's just the level of tachypnea and hypoxemia they end up having which is the determining indication for me.