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Medical practitioners: would you be interested in sharing data about COVID-19?

Discussion in 'Off Topic' started by charliesgrave, Mar 26, 2020.

  1. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    Talking with some people I work with and know, there is confusion and fear about managing COID-19 patients, but there's some good data out there, mostly based on ARDS and SEPSIS protocols.

    How many of us are there and would you be interested in sharing information? Obviously not breaking HIPPA, but if you're seeing anything that seems to work, or note any trends, or have links to research-based information or guidelines, there's no reason not to share with each other.
     
  2. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    I manage vents, so I'm familiar with ARDS protocols, but this guy's vid gives a good overview of what WHO is recommending based on what little data we have.



    Here's a run-down:

    PATIENT RISK FACTORS:
    Elderly, males, comorbidities (diabetes, HTN, asthma, COPD, etc).

    19% of patients present with hypoxemic respiratory failure
    14% present needing oxygen therapy
    5% critically ill ICU admit needing ventilation

    Of those critically ill:

    63.5% will require HFNC.
    56% will require Mechanical ventilation
    60-70% of those will develop develop ARDS

    OXYGEN THERAPY
    For those who will need fio2. Start therapeutic fio2 at < 92% sat.
    Spo2 target range 92-96% WHO recommends >90%

    Start with conventional low flow,(NC, mask, etc)

    If not able to keep normoxic, move to HFNC (high flow nasal cannula- optiflo or whatever that looks like in your clinical setting)
    HFNC suggested over NiPPV due to risk of transmission, increased comfort, better outcomes
    (HFNC does not seem to increase risk of disease transmission according to WHO based on SARS outbreak study)

    NiPPV (BiPAP, CPAP)
    Only if HFNC not available. Trial NiPPV, closely monitor for deterioration, intubate at first signs of failure.

    No recommendation for interface type (mask/helmet/nasal mask, etc.)
    Increased risk of contamination due to aerosol.
    High failure rate used in non-cardiogenic etiologies, worse outcomes after mechanical ventilation (>50% failure rate)
    Delaying intubation increases risk to patient and providers

    Here's a spot where EMS probably need to skip support measure and just intubate if you suspect they are infected, otherwise you're creating even greater risk for yourself and the patient.

    MECHANICAL INTUBATION
    Little data for this outbreak, mostly based on ARDS guidelines and Chinese data.

    Low tidal volume ventilation consistently shown to improve outcomes in ARDS
    Recommend 4-8 ml/kg IBW
    Start at 6ml/kg IBW
    Follow ARDS guidelines
    Plateau pressure < 30 cm h20
    Low vt and low plateau pressure shown to reduce mortality in ARDS.
    High PEEP strategy. 10 or greater. Individualized for patient.
    Monitor for barotrauma. Limit driving pressure (Plat – PEEP).

    Avoid ventilator circuit disconnections due to loss of lung recruitment and infection control. Use inline suction catheters, clamping ETT while disconnection from ventilator.

    Recruitment maneuvers: no specific COVID-19 data. Other clinical data unclear.
    If patient's hypoxemic in optimized ventilator settings, suggest recruitment maneuver over no recruitment maneuver. Recommend against “staircase” maneuver, use sustained inflation. Mixed data about which patient may respond to recruitment maneuvers. Case by case basis.

    FLUID MANAGEMENT
    Some Chinese data suggests cardiac failure alone or in combination with respiratory failure the result of 40% of COVID-19 deaths.
    Conservative fluid strategy recommended by WHO. Shown to reduce the duration of ventilation without difference in renal fail, etc.
    Don't pump suspected cases full of fluid!

    PRONE POSITIONING
    12-16 hour sessions recommended by WHO reduces mortality.
    Proning sessions less than 12 hours not shown to reduce mortality.
    Consider risks such as pressure sores, tube and line occlusions, brachial plexus and other peripheral nerve injury, contamination, resource intensive.

    NEUROMUSCULAR BLOCKERS
    WHO suggests considering use.
    SEPSIS guidelines consider PRN use to protect ventilation (unable to get plat below 30, etc)
    Suggest continuous infusion up to 48 hours for persistent dyssynchrony on vent, persistent high plat pressures.

    OTHER CONSIDERATIONS
    Against routine use of nitric oxide (NO), reasonable to attempt as trial for rescue therapy. Taper quickly if no improvement. (not readily available most places anyway)

    ECMO
    For refractory hypoxemia in failure of other methods and strategies (not available very many places either)

    Resources used in the vid:

    https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19

    https://www.who.int/publications-de...vel-coronavirus-(ncov)-infection-is-suspected

    Other resources:
    ARDS NET
    http://www.ardsnet.org/
    Vent protocols and fluid management information here.

    Also a handy IBW/PBW card for males and females:
    http://www.ardsnet.org/files/pbwtables_2005-02-02.pdf
     
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  3. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    [​IMG]

    Can't speak for the validity of everything on this one, but some of the information mirrors the vent protocols.
     
    Last edited: Mar 26, 2020
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  4. FourSpeed426

    FourSpeed426 New Member

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    https://spice.unc.edu/coronavirus-resource-page/ there is a pretty good power point on there, especially tword the end. Was a living document since I've been following it 2nd week of January. Real data driven (some skewed by Chinese collection) but seems to be evidence based.
     
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  5. FourSpeed426

    FourSpeed426 New Member

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    If you manage vents then I assume you're transport, RT or CCRN so you are more into long term management than myself. I was on staff for the first positive swab for the CLT metro area, and these cases we are seeing fall into a handful of categories.

    Firstly, with protocols for testing changing so quickly, what was relevant a week ago, for testing has, and will continue to change.

    When the sick as shit ones come into the ED, other than PPE its sepsis protocol and airway management business as usual.

    Next we've got visually sick and uncomfortable people. Just a across the lobby glance they look like the flu. Added to that almost have a uncontrollable dry cough. We've CT most of these and its ground glass city in their chest. Seeing that for weeks now. And up until labcorp and quest swabs, if they were under 100.4 temp (which most were) they didnt get a covid state swab. Most were afebrile and able to maintain RA sats low to mid 90s, so D/C to home and assume quarantine.

    Then there are patients that probably more in a urgent care or PCP workup category. Look like they dont feel well but mild fever, maybe no fever, cough sore throat. C/O sob but dont look it nor have any issue rambling on.

    Further still some c/o symptoms that they dont exactly present with on exam. Depending on provider and their story of confirmed contact they maybe get swabbed. Maybe not.

    Last are the who the hell knows. Yesterday pulled a chick out of a car who had a pocket full of xanny bars and had suboxone listed on home meds. Not breathing, no pulse. Worked her for a while ofcourse. After the dust settled family said bronchitis type symptoms for week PTA that didnt improve with antibiotics. So who knows with that one.

    I'd be interested to know what yall are doing long term management wise. Maybe could influence our short time we have them and improve outcomes for some of these folks.
     
    Last edited: Mar 28, 2020
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  6. bigfelipe

    bigfelipe Phil-osopher... Charter Life Member

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    what do you mean by ground glass?
     
  7. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    We've been lucky to avoid any critical patients yet, but I'm sure it's coming. The couple I've dealt with are still ongoing with nothing more than nasal cannula support, low flow fio2.

    Honestly, in the past we've shipped ARDS patients, but that's probably not an option anymore. We can, in theory prone our patients, but have never used true proning on a vent patient (though I have used good lung down to aid in positional ventilation on some specific cases).
    I'm trying to gather up whatever small bits of information I can right now from places that are in the thick of it. I don't want to discover how to streamline things through attrition if I don't have to. Small things like keeping an IBW table bedside for adjusting vt. Figuring out how to clamp an ETT to maintain PEEP if we have to change filters, etc.

    Right now there's almost a hesitancy to even test. When we are testing, results can take up to a week, so we've had several patients treated as positive who were eventually diagnosed flu or RSV positive. I don't see these patients come in, and generally wont unless they are headed for a tube or the ED doc wants a second opinion/assessment.
     
  8. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    ARDS is commonly described as having a "ground glass" appearance on chest imaging. Looks like someone took a handful of broken up glass and threw it across the picture.
     
  9. bigfelipe

    bigfelipe Phil-osopher... Charter Life Member

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    is it permanent or does it heal?
     
  10. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    Generally you either get better or die. However, ARDS can leave a person with lung damage even if they pull through.
    You can end up with pulmonary fibrosis- lung tissue gets scarred and doesn't work well anymore. Pulmonary fibrosis does not heal.
     
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  11. FourSpeed426

    FourSpeed426 New Member

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    Charliesgrave is correct, not that he needs my validation.

    Reason I brought that pattern up is it has been a presumptive sign of covid19. Some of the folks had a clean (or needing clarification) CXR. South Korea and China would end up just skipping the nasopharyngeal covid swab and go right for the CT chest looking for that ground glass pattern.

    I've seen the probe position in NY and heard that form some fellow ED staff up there that their icu counterparts had luck in their ICU/CCUs with that technique. Most of what I've seen is bilateral involvement in the lungs so with the good lung down technique maybe less effective. Side note, first time an RT showed me that it was like watching witchcraft! I was so impressed! I've done that with my tubed 20s-30s vaper crowd to good success.

    You're right about the hesitation to swab by some. We are, and will continue to see more loosening of swabbing protocol. Or the opposite and mild cases get a presumptive DX and sent home while admission cases swab or CT chest. Something about these swabs is I've heard fail rate and false negatives are pretty high. Similar numbers in failure of flu swabs.

    I've been hearing this nebulizers and some other RT equipment that circulates air outside the patient have been spreading in into the air in the room. Have you heard the same?

    Be careful, its out there plenty now. It's been over 2 weeks since we saw our first groundglass CT pattern. Fine line on HIPAA with that case but they didnt get swabbed because only a mild fever. Travel but not to the hard hit places on the CDC list at that time. We picked it up ruling out a PE and felt like covid screen was gravy.

    For my own safety I've been treating any respiratory pt as a PUI in my precautions. Remember they are seeing lots of this is already comprised respiratory PTs. So what looked like a copd, chf, asthma exacerbation very well could be that now, just with covid on board. Just my opinion and mindset of (avoid) being exposed
     
    Last edited: Mar 28, 2020
  12. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    No solid data I can find except relating to the SARS outbreak, but most hospitals and clinics (mine included) have stopped using nebs on suspected cases and went to metered dose inhalers.
    BiPAP/CPAP most certainly will. Every mask and unit has an exhalation port somewhere pushing air out fast enough to aerosolize anything that gets pushed through. Some hospitals have developed work arounds by plugging HEPA filters inline as best they can, but it's still risky.
    Jury is out on high flow nasal cannula, humidified or not. I would think it's less risky overall, but I've seen at least one hospital a friend works at refuse to use HFNC with presumptive COVID patients. They go from nasal cannula, to non-rebreather or air entrainment mask, and then right to the tube.

    I think that's a solid way to operate. I've rarely seen a patient come in with COPD exacerbation, CHF exacerbation, or anything else and immediately develop ARDS, though some have been close.
    From what I'm seeing of the available CXR's, it's always bilateral as well, so as you say, "good lung down" strategies are probably not going to be very useful unless they show marked improvement on one side and are still failing to oxygenate/ventilate.

    That's the way I'm playing it. Respiratory distress or cold and flu symptoms immediately make me suspicious. I see our familiar patients come in with their monthly exacerbation and I'm going to first assume they are also infected.
     
  13. Doctor SigFan

    Doctor SigFan Back at home Benefactor Charter Life Member

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    My “go to” site in all this is a YouTube channel called MedCram.com. It’s run by a pulmonologist in California. He has made available his videos on mechanical ventilation and modes of ventilation. He’s also doing nearly daily updates on COVID-19 epidemiology. He has a pay site as well which has been approved for CME, but all his important stuff is free.
     
  14. FourSpeed426

    FourSpeed426 New Member

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    Very smart about just assuming the frequent flyers are infected. Also about the humidified o2 is interesting, I had not considered that but it makes sense.

    Check out the link I posted in my first post on the thread. It is a lengthy power point but has been one of the best information sources I've been referred to yet. It's been cool to see how its changed since January too. Hoping they update it again.

    Thanks for starting this post btw! I've refrained from posting on other covid threads for multiple reasons. -Jim
     
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  15. Doctor SigFan

    Doctor SigFan Back at home Benefactor Charter Life Member

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    Here’s the link for ventilator management:



    This has been posted before but worth reviewing for medical personnel who may be brought into their local hospitals for an “all hands on deck” scenario.
     
    Last edited: Mar 28, 2020
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  16. Sevenshot

    Sevenshot Active Member

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    I'm at the Durham VA on Monday. I'll post what they're doing once I find out.
     
  17. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    I've glanced through the PP, but hopefully things are quiet tonight and I can actually digest it.

    I'd be very curious what everyone's organization is doing with CPAP/BiPAP. The minute a patient is considered PUI, they are a no go for us, which may lead to chf exacerbations etc who we could turn around getting tubed instead.
     
  18. FourSpeed426

    FourSpeed426 New Member

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    Our facility mirrors that as well. Acceptable risk to end up getting tube they say. I just called RT to ask just now
     
  19. Scsmith42

    Scsmith42 Member Benefactor Charter Life Member

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    This is the most intelligent and comprehensive explanation for a layman of Covid-19 that I have seen. It is worth your time to watch. It is the first of three videos that address what it is, how it spreads, how it kills, and why it is important to give this serious attention.

     
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  20. phideux

    phideux Member

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    On the ambulance now, we are "strongly discouraged" against any Nebs or C-PAP in the back of the unit, unless totally necessary. Do any nebs on scene, preferably outside, before transport. If you have to neb in the ambulance, a face shield and mask is required, also required if you have to C-PAP someone, along with putting a HEPA filter on the exhaust port. Intubation, mask and gown.
     
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  21. charliesgrave

    charliesgrave cosmoline enthusiast Benefactor Life Member Supporting Member

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    Stay safe out there guys.

    A member of our staff was harassed in a grocery store because she was wearing scrubs. Cussed at and threatened violence from some soccer mom because she "is putting us all at risk!". Between the tinfoil hatters, the ones in full freakout mode, and the anti-intellectuals who think this is a big joke, things might get more hairy for us.

    The kicker is she was not coming from the hospital, but was trying to buy some food to take with her for her shift.