Friday, March 27, 2020

Nutrition and Gut Health in the ICU: Citations

References to the Enteral Nutrition Lecture

Lambell KJ, Tatucu-Babet OA, Chapple LA, Gantner D, Ridley EJ. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care. 2020;24(1):35. Published 2020 Feb 4. doi:10.1186/s13054-020-2739-4

McClave SA, Martindale RG, Rice TW, Heyland DK. Feeding the critically ill patient. Crit Care Med. 2014;42(12):2600–2610. doi:10.1097/CCM.0000000000000654


McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) [published correction appears in JPEN J Parenter Enteral Nutr. 2016 Nov;40(8):1200]. JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. doi:10.1177/0148607115621863

Nguyen NQ, Besanko LK, Burgstad C, et al. Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients. Crit Care Med. 2012;40(1):50–54. doi:10.1097/CCM.0b013e31822d71a6

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307(8):795–803. doi:10.1001/jama.2012.137

Arabi YM, Aldawood AS, Haddad SH, et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults [published correction appears in N Engl J Med. 2015 Sep 24;373(13):1281]. N Engl J Med. 2015;372(25):2398–2408. doi:10.1056/NEJMoa1502826

Arabi YM, Aldawood AS, Al-Dorzi HM, et al. Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial. Am J Respir Crit Care Med. 2017;195(5):652–662. doi:10.1164/rccm.201605-1012OC

Al-Dorzi HM, Albarrak A, Ferwana M, Murad MH, Arabi YM. Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. Crit Care. 2016;20(1):358. Published 2016 Nov 4. doi:10.1186/s13054-016-1539-3

Allingstrup MJ, Kondrup J, Wiis J, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med. 2017;43(11):1637–1647. doi:10.1007/s00134-017-4880-3

Harvey SE, Parrott F, Harrison DA, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014;371(18):1673–1684. doi:10.1056/NEJMoa1409860

Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013;309(20):2130–2138. doi:10.1001/jama.2013.5124

Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365(6):506–517. doi:10.1056/NEJMoa1102662

Halpern SD, Becker D, Curtis JR, et al. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med. 2014;190(7):818–826. doi:10.1164/rccm.201407-1317ST

Reignier J, Boisramé-Helms J, Brisard L, et al. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2018;391(10116):133–143. doi:10.1016/S0140-6736(17)32146-3

TARGET Investigators, for the ANZICS Clinical Trials Group, Chapman M, Peake SL, et al. Energy-Dense versus Routine Enteral Nutrition in the Critically Ill. N Engl J Med. 2018;379(19):1823–1834. doi:10.1056/NEJMoa1811687

Wischmeyer PE. Enteral Nutrition Can Be Given to Patients on Vasopressors. Crit Care Med. 2020;48(1):122–125. doi:10.1097/CCM.0000000000003965

Doig GS, Simpson F, Heighes PT, et al. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med. 2015;3(12):943–952. doi:10.1016/S2213-2600(15)00418-X

Lambell, K.J., Tatucu-Babet, O.A., Chapple, L. et al. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care 24, 35 (2020).

van Niekerk G, Meaker C, Engelbrecht AM. Nutritional support in sepsis: when less may be more. Crit Care. 2020;24(1):53. Published 2020 Feb 14. doi:10.1186/s13054-020-2771-4

Wischmeyer PE, McDonald D, Knight R. Role of the microbiome, probiotics, and 'dysbiosis therapy' in critical illness. Curr Opin Crit Care. 2016;22(4):347–353. doi:10.1097/MCC.0000000000000321

Fay KT, Klingensmith NJ, Chen CW, et al. The gut microbiome alters immunophenotype and survival from sepsis. FASEB J. 2019;33(10):11258–11269. doi:10.1096/fj.201802188R

Robinson CM, Pfeiffer JK. Viruses and the Microbiota. Annu Rev Virol. 2014;1:55–69. doi:10.1146/annurev-virology-031413-085550

Lozupone CA, Stombaugh JI, Gordon JI, Jansson JK, Knight R. Diversity, stability and resilience of the human gut microbiota. Nature. 2012;489(7415):220–230. doi:10.1038/nature11550

Clark JA, Coopersmith CM. Intestinal crosstalk: a new paradigm for understanding the gut as the "motor" of critical illness. Shock. 2007;28(4):384–393. doi:10.1097/shk.0b013e31805569df

Zhao L, Luo L, Jia W, et al. Serum diamine oxidase as a hemorrhagic shock biomarker in a rabbit model. PLoS One. 2014;9(8):e102285. Published 2014 Aug 21. doi:10.1371/journal.pone.0102285

Lankelma JM, van Vught LA, Belzer C, et al. Critically ill patients demonstrate large interpersonal variation in intestinal microbiota dysregulation: a pilot study. Intensive Care Med. 2017;43(1):59–68. doi:10.1007/s00134-016-4613-z

McDonald D, Ackermann G, Khailova L, et al. Extreme Dysbiosis of the Microbiome in Critical Illness. mSphere. 2016;1(4):e00199-16. Published 2016 Aug 31. doi:10.1128/mSphere.00199-16

Shimizu K, Ogura H, Goto M, et al. Altered gut flora and environment in patients with severe SIRS. J Trauma. 2006;60(1):126–133. doi:10.1097/01.ta.0000197374.99755.fe

Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012;307(18):1959–1969. doi:10.1001/jama.2012.3507

Weng H, Li JG, Mao Z, et al. Probiotics for Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated Patients: A Meta-Analysis with Trial Sequential Analysis. Front Pharmacol. 2017;8:717. Published 2017 Oct 9. doi:10.3389/fphar.2017.00717

Manzanares W, Lemieux M, Langlois PL, Wischmeyer PE. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis [published correction appears in Crit Care. 2017 Feb 27;21(1):42]. Crit Care. 2016;19:262. Published 2016 Aug 19. doi:10.1186/s13054-016-1434-y

Goldenberg JZ, Yap C, Lytvyn L, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017;12(12):CD006095. Published 2017 Dec 19. doi:10.1002/14651858.CD006095.pub4

Yelin I, Flett KB, Merakou C, et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat Med. 2019;25(11):1728–1732. doi:10.1038/s41591-019-0626-9

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Gaines S, Alverdy JC. Fecal Micobiota Transplantation to Treat Sepsis of Unclear Etiology. Crit Care Med. 2017;45(6):1106–1107. doi:10.1097/CCM.0000000000002382

Alagna L, Haak BW, Gori A. Fecal microbiota transplantation in the ICU: perspectives on future implementations. Intensive Care Med. 2019;45(7):998–1001. doi:10.1007/s00134-019-05645-7

Dai M, Liu Y, Chen W, et al. Rescue fecal microbiota transplantation for antibiotic-associated diarrhea in critically ill patients. Crit Care. 2019;23(1):324. Published 2019 Oct 21. doi:10.1186/s13054-019-2604-5

Wurm P, Spindelboeck W, Krause R, et al. Antibiotic-Associated Apoptotic Enterocolitis in the Absence of a Defined Pathogen: The Role of Intestinal Microbiota Depletion. Crit Care Med. 2017;45(6):e600–e606. doi:10.1097/CCM.0000000000002310

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Multiple Patients on a Ventilator: FAIL

Sometimes medicine behaves like the stock market; a whole bunch of enthusiasm followed by a realistic pullback. This has now occurred with the concept of using one ventilator for multiple patients. I agree that we need to use some ingenuity in this crisis, but this one never sat well with me, hence me not commenting on it at all until now. Too many nuances go into oxygenating and ventilating patients with ARDS. I understand trying this to hold down the fort in a severe crunch, and I tip my hat to those who created the articles and YouTube videos. I'm not trying to be a contrarian or a Debbie Downer.

This statement was put out by the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (ASPF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST).

Amongst things mentioned here, all patients would need to be paralyzed for this to maybe work. What happens after the 48 hours of paralytics runs it course and they can't play nice on the vent anymore? One always needs an exit strategy. This is something I always teach when taking care of patients in the ICU. I digress, the list provided shows some other safety reasons.

We need to continue thinking outside the box, though, to save all the lives we can. I have never seen our community come together so well. We have done a great job supporting each other. Many have said it already and I agree with them, many of us are going to come out of this psychologically altered. Many of us are, what some would call, jaded in things of life and death. It's part of our daily lives in Critical Care. But this is taking that to another extreme. I appreciate the support that I have received from the community as well. Hope to keep providing you all with great content.

-EJ



Link to ASA Position Statement

Link to SCCM Position Statement

Link to PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Thursday, March 26, 2020

COVID-19 Extubation Protocol (in the works)

Many questions on how to extubate these patients. There's no right answer yet. I've read of a high reintubation rate for these patients and cardiac arrest after extubation we need to be prepared for that. This is a living, breathing document. I would like to make changes as you all point out things that I have missed. 

Prior to extubation:
Before getting to the point of extubation, I would favor a prolonged version of 0/5 or 5/5 on PSV due to high rate of reintubation, possibly even T-piece. Allow the lungs to de-recruit. My opinion. Make sure the patient can tolerate this. As mentioned earlier, I have heard of significant reintubation rates with crashing and burning of patients. One must also have to wait a while until the proper crew and gear is ready. 

The extubation itself:
The extubation procedure must be treated like an aerosol generating procedure (bronch, intubation, etc.). Full PPE for staff, N-95, PAPPR, full draping, etc. Should only require 2 people. The unanimous response of everyone I have asked directly have included undoing the restraint, deflating the cuff, and running out the room. This is hilarious but not realistic. We should not encourage the patient to cough. Good luck with that. 

Supplemental O2:
Clinical judgement comes into play here. We all have concerns about aerosolizing the virus and questions regarding which device hypothetically causes more or less of this. Hopefully the patient needs just room air. Then next comes the regular nasal cannula. I'll defer to your clinical judgement and patient scenario on what you choose to use after that. 

Unclear Questions:
How long to remain in airborne precautions?
At least 3 hours (this is based on the NEJM study I reference earlier). After that, I would put a surgical facemask on the patient, if available, for when the cough they don't get it all over the place. My vote would be to be in an N95 anytime around a COVID patient but that's unrealistic. 

Should we check a viral load prior to extubation?
In a perfect world I would love to know whether the patient is still infectious or not. Right now the testing that most institutions is lackluster at best with not enough testing available and too long a turnaround time. Treat everyone as if they're still infectious. 

Addendum: there are photos circling around about putting big plastic bags around patient's head to contain the cough and pre-fill it with heliox. I have zero experience with this. I would like to see how you all do your thang!



Medical Journal of Australia- PDF



IBCC: Josh Farkas



ANZICS Guidelines

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Tuesday, March 24, 2020

Plasma to treat COVID-19?

The FDA is opening up clinical trials to see if convalescent plasma (you know, plasma from people who have defeated COVID-19) helps treat individuals with severe COVID-19 infections. I basically took screenshots of the info so we can get some clinical trials going. But first, we need some donors. Lots of limitations to enrolling people simply bc it was so hard to diagnose people in the first place but that’s a story for another day. If you discharge someone from your shop after recovering from COVID, potentially talk to them about donating plasma. Hopefully the data proves it’ll save some more lives.


Link to FDA Document




Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Anosmia and dysgeusia

I took a day off from the whole COVID situation yesterday (which I recommend you do if you can) and sat on the sidelines. I didn't see anything monumental to post about and the rest of the social media community posted great work. I didn't have anything important to add. I'm trying to figure out ways to take care of all of us in this order.

That being said, last night when I was scrolling around twitter before going to bed, I ran into many articles regarding the anosmia/hyposmia (loss/decreased of sense of smell) and dysgeusia (loss of sense of taste) in patients with COVID-19. Let's dig into this some more. By no means am I an ENT nor the most knowledgable person in the cranial nerves. This is a relatively new rabbit hole I'm digging into. Join me in this journey.

The reason why I am going into this is because it could be particularly helpful in the healthcare worker population because we are typically quite healthy and may be asymptomatic carriers. This could be the only symptom and may be worth considering self-isolation or testing (or wearing two bandanas instead of one). We can't get ourselves nor our teammates sick. Unfortunately, with how testing is going right now, people presenting with this do not meet criteria for testing or self-isolation.

The links to everything I am mentioning here are on my website: eddyjoemd.com. The AAO (American Academy of Otolaryngology) mentioned in a statement on 3/22 that we are receiving a good amount of anecdotal evidence "from sites around the world that anosmia and dysgeusia are significant symptoms associated with the COVID-19 pandemic." Is this something that's new? Well, no. ENT-UK states that "post-viral anosmia is one of the leading causes of loss of sense of smell in adults, accounting for up to 40% cases of anosmia."

This is particularly a big deal because a basketball player says he has it. Maybe the WHO and CDC will list it as part of the symptoms now.

Anosmia incidence:
South Korea- 30% of patients testing positive have had anosmia as their major presenting symptom in otherwise mild cases. (ENT-UK)
Germany- up to two-thirds “described a loss of smell and taste lasting several days”

While digging into this, since there is nothing in the peer-reviewed journals about the matter, I found it comical how many different news mediums published the same exact article just slightly re-written. You know, similar to what I have done here. Stay safe everyone!

-EJ

ENT-UK Document

American Academy of Otolaryngology— Head and Neck Surgery

Livescience.com

German Data

Rudy Gobert has anosmia


Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Saturday, March 21, 2020

Why do we give Corticosteroids during Septic Shock?

Whether you're a med student, intern, resident, or nurse, you've wondered why in the world we give patients who are in septic shock stress dose steroids. This article breaks down in a not-so-easy to understand fashion of the nitty details that are too complex for my post-night shift brain to digest.

The powers that be in Critical Care, SCCM and ESICM, got together for this review with some big guns in the field to write this review discussing Critical Illness-related corticosteroid insufficiency.

Link to Abstract

Link to FULL FREE PDF

Annane D, Pastores SM, Arlt W, Balk RA, Beishuizen A, Briegel J, Carcillo J, Christ-Crain M, Cooper MS, Marik PE, et al.: Critical illness-related corticosteroid insufficiency (CIRCI): a narrative review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 43(12):1781–1792, 2017.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Friday, March 20, 2020

Hydroxychloroquine and Azithromycin as a treatment of COVID-19

First of all, credit to the authors. Huge hat tip to them.

Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label non‐randomized clinical trial. International Journal of Antimicrobial Agents – In Press 17 March 2020 – DOI : 10.1016/j.ijantimicag.2020.105949


First of all, there are a substantial amount of limitations to the study but in my opinion, not medical advice, it provides a glimmer of hope. 

Let's begin
Where was it performed: French study (thank youuuuuu!)
Population: NOT ICU Patients! But we've learned that non-ICU patients become ICU patients extremely quick! 
n=36 (20 hydroxychloroquine, 16 control)
How did the determine the Viral load? Nasopharyngeal swabs daily
Questions I have: 6 patients (originally n=42) lost to follow up. Patients who were transferred to the ICU were considered to be "lost to follow-up" (n=3). I can't tell if the one patient who died was transferred to the ICU. Hopefully the edits will sort this out. Why didn't they just follow those patients who ended up in the ICU?
Age groups were not matched but this would favor the control group as the experimental group was older. More were male in the experimental group which we assume that males get this worse than females. More asymptomatic patients in the control group, also bodes worse for the experimental arm.

3 classifications: asymptomatic, upper respiratory, lower respiratory

Regimen:
Hydroxychloroquine 600mg daily (200mg TID x 10 days)
+/- azithromycin depending on clinical presentation (500mg on day 1, 250mg x 4 days) 

Results
At day 6, 70% of hydroxychloroquine group were virologically cured vs. 12.5% in control group (p=0.001) NNT = 1.7!! 

100% of hydroxychloroquine + azithromycin were virologically cured vs 57.1% in the hydroxychloroquine only group vs. 12.5% in the control group (p0.001)

Drug effect was higher in URI and LRI than asymptomatic patients (p=0.05)

Starts working in 3-6 days per this data. 

Careful with the QT prolongation on the EKG! Replete the Mg as needed for this. Monitor liver function. My pharmacy friends can contribute some more adverse effect stuff like retinopathy, etc.  

I cannot make any recommendations as I do not give medical advice but I know what I would do with this data to save a life. 

-EJ


Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

SCCM/ESICM Guidelines on COVID-19

The Society of Critical Care Medicine and the European Society of Intensive Care Medicine came together for these guidelines regarding COVID-19. Thank goodness they didn’t include 30cc/kg bolus for an elevated lactate 🤣. I figure this will be revised as more data comes out in the upcoming weeks, especially regarding the therapies as Kaletra was recently mostly disproven to have a benefit. 

Many of the recommendations included are not new to us who are on the cutting edge of Critical Care medicine but it’s always good to share concepts such as conservative fluid management , using balanced crystalloids over 0.9% saline, not using dopamine. They have relaxed their MAP goals. I wonder if that has to do with the new trials on MAP goals in the elderly since this predominantly affects the elderly. Hmmmm need to look into that some more. They also stress the importance of proning patients. If your shop doesn’t prone, I have posts and guidelines for this on this page and my website. 

I’ll try hard to answer your questions but there’s a lot going on and I’m quite busy with a number of other tasks I’m helping out with. Best of luck to you all!

- EJ

Link to FULL FREE PDF

Link to SCCM Page



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Wednesday, March 18, 2020

Kaletra (lopinavir–ritonavir) did not work in COVID-19 :(

Trials are starting to come in. I'm not going to belabor the fact but it appears that Kaletra, also known as lopinavir–ritonavir (400 mg and 100 mg, respectively) does not work for patients with COVID-19. I'm not going to dissect the article for you all as this is more intended to be a news bulletin of sorts. It is important to note that they used the sickest of the sick patients in the study. This does not mean that data in the future will say that it cannot help in those less ill but I really don’t see anyone trying at this point.

No difference in clinical improvement, mortality, nor decrease in viral load. Please read the article for yourself if you're using this at your institution. I do not provide medical advice. A 🎩 tip to the authors.

I have seen it in the protocols for several institutions that have been sent to me. I will never EVER disclose any information that you all send me via email without discussing it with you all first.

Tomorrow is my 38th birthday so I'll be celebrating it with a ton of social distancing and maybe a trip to a more secluded beach.

Thank you for your support. The page is growing fast but I wish it was slower and I didn’t have so much to post about regarding a deadly virus that is changing our lives so rapidly. ☹️


-EJ

Link to Abstract


Link to FULL FREE PDF

Cao B, Wang Y, Wen D, et al. A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. N Engl J Med. DOI: 10.1056/NEJMoa2001282.



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.


COVID-19: Airborne or Droplet Precautions

This is a widely contested topic that I feel we still do not know the full answer on, but I am feeling better about.

As of right now, though, it seems hospital administrators have a leg to stand on when they recommend face masks for the majority of cases and N95's/respirators for NIV, intubations, bronchs, nebs, etc. I don't know if this is an official recommendation by any agency, but patients who have COVID-19 or are being ruled out for this should wear a mask in the hospital and outside the hospital. 

The flip flopping of policies occurs as we learn more data. It seems shady to me that they flipped their policies as shortages occurred, but it seems as if it's defensible at this time.

WHO: The February 27, 2020 guidance paper states:

"Healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask and eye protection (goggles or face shield)."

"Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy) healthcare workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant."

CDC: updated recommendations on March 10, 2020:

"Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand.
During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP."

Essentially, they are acknowledging that we are being put at risk due to the lack of masks.

The most recent stir and adding to the controversy was a recent publication NEJM published on 3/17/20 which states:

"SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours)"

"The half-lives of SARS-CoV-2 and SARS-CoV-1 were similar in aerosols, with median estimates of approximately 1.1 to 1.2 hours"

"Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed)"

The key point is that the authors went out of their way to both nebulize the virus AND fed it into a Goldberg drum to further disperse it (I don't know what that is and google wasn't too helpful).

It is admittedly outside my scope of knowledge how to interpret the titers in the air, but it seems as if it's there and transmissible to us, the boots on the ground. I cannot make a concrete declaration based on my level of knowledge. I'd welcome your interpretation. I am curious to see how the ever-intelligent people in the CDC and WHO react to this data and possibly adapt their recommendations. 

We should also reach out to the local news agencies to assist us in asking the N95 hoarders to donate their extras to the local hospitals. We need to protect each other. 

-EJ

Link to the WHO Interim Guidance Paper

Link to the CDC Information

Link to the NEJM Abstract


Link to the NEJM PDF



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Tuesday, March 17, 2020

How to take off your PPE after caring for COVID-19 patients

The first time I walked into a the room of a patient with suspected COVID-19 I was very methodical with every step. I had done my required reading. I had an N95, a face shield over that, a hair net, the stupid yellow contact gown, double gloves. At the same time I felt naked. I had seen the people on TV and in other countries in basically hazmat suits. The uncertainty was driving me bonkers but I needed to take care of the patient ASAP. The nurse and I got everything together and we went in. We took care of the patient. When it was time to come out, the same methodical steps took place. But somewhat in reverse. It’s hot in there with all that gear when you have to put on the sterile gown for procedures and the sterile gloves on top of my double gloves. Since the I have walked into a number of rooms and am getting the feeling that this is going to be the new normal for the next few months. I felt it was important to do a second post today to share the CDC guidelines on how to put on and take off the personal protective equipment. I have attached the images from this as well. Feel free to share with your friends.

I was inspired to create this post after seeing @doctorwarsgame’s similar post. I must give him credit. I also sent meme, as I am not someone who creates them on this medium, to @bedsideroundz for his approval. He actually was the one who suggested that I use it to teach people the correct way to do it.

Thank you all for your support.

CDC Guidelines for Healthcare Personnel PDF



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.


Monday, March 16, 2020

Airway pressure release ventilation

We are already seeing severe ARDS from these patients infected with COVID-19. There's discussion out there regarding VV-ECMO, proning, and numerous other strategies to help oxygenate and ventilate our patients. There are numerous different modes on the ventilator to help us achieve these goals but I have found none to be more polarizing than airway pressure release ventilation which is also called APRV. On the Servo vents this is called BiVent (just adding to the confusion of terminology).

Since we are in the process of contemplating providing our patients with anti-retrovirals and anti-malarial drugs, I feel that some of us should reach out of our comfort zone and familiarize ourselves with APRV. If I'm being completely honest, I haven't needed this mode of ventilation much since fellowship. I haven't had many patients in whom I have had such a hard time oxygenating them where I have to reach for this mode. I tend to paralyze patients which is definitely NOT recommended in patients with APRV therefore ameliorating the benefit. I am aware of the PETAL study (Early Neuromuscular Blockage in the ARDS, NEJM 5/2019) which did not show a benefit to paralytics, by the way. My experience is therefore limited, thankfully for my patients who haven't needed me to venture down this road.

The data for APRV is not the most robust, but this recently published review this month contains some great tables and recommendations including the indications and contraindications for APRV, how to set up the vent to initiate APRV, how to troubleshoot the vent depending on the different physiological derangements (I find hypercapnia to be the most common of these personally), and lastly how to wean the vent. I feel the authors did a great job and definitely a good resource to have in your article collection. Stay safe everyone!

A hat tip to the authors.

-EJ

Link to Abstract

Link to FULL FREE ARTICLE







Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.


Sunday, March 15, 2020

COVID-19: Don't order unnecessary nebulizations!!

Colleagues, I know that lots of us have knee-jerk tendencies to order nebulizations on everyone who is on a ventilator, NIV, or any type of shortness of breath under the sun because it makes us feel warm and fuzzy inside where we say "I did something". This behavior needs to stop. We are potentially aerosolizing the virus and putting our teammates at risk. COVID-19 does not appear to be an airborne virus, it is a droplet precaution virus. We need to take care of our patients but we can't go down ourselves. Let stop with the unnecessary tests and treatments. We should not have our respiratory therapists and nurses being unnecessarily exposed, simply the process of going in and out of the room, for no beneficial reason to the patient. We're at war here. We need all of our soldiers intact to help us in this fight. Stop the unnecessary practices.

This data is pulled from the SARS outbreak. Both of these articles are free.

- EJ



Link to FULL FREE Article


Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet. 2003;361(9368):1519–1520. doi:10.1016/s0140-6736(03)13168-6



Link to FULL FREE Article

Loeb M, McGeer A, Henry B, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis. 2004;10(2):251–255. doi:10.3201/eid1002.030838



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.



Friday, March 13, 2020

US Ventilator Resources for COVID-19

I have purposefully kept quite and obtained data regarding the COVID-19 outbreak. I don't like to open my mouth or write unless I have a pretty good grasp on what is going on. My crew and I are going to be on the front lines when this thing hits, and I believe it's going to hit. I hope I'm wrong. The majority of the people who follow my page are going to be on the front lines, too. That being said, the system is going to be stressed for resources. I have already heard from different regions of the country and I'm concerned. 

The Society of Critical Care Medicine just sent out an email discussing resource availability. 
I'm more concerned after reading this letter. The data is extremely outdated in many parts. The numbers are obtained from the American Hospital Association which were obtained via voluntary survey. Here's an example: in 2009 we had, in the country, 62000 vents. We have almost 99000 old vents (I don't know what this means nor where they are bc they mention that 23k are NIV, 33k are automatic resuscitators, and 8500 are CPAP units). The strategic national stockpile has 8900 ventilators ready for deployment. 

We're looking at an estimated total of 200,000 ventilators in the country. 

They crunched the numbers based on the number of people who end up on the vent with COVID-19. We could reasonably expect 960,000 to require ventilatory support. I don't know if ventilatory support means non-invasive ventilation + high flow nasal cannula + mechanical ventilation or just MV. I've read about avoiding NIV and HFNC as they aerosolize the virus but I need to learn more. 

It's great to see that we have more critical care beds per capita than anywhere else in the world, but who is going to take care of those patients when there's a limited supply of healthcare professionals who are trained to take care of the critically ill? 

I see this as us being in deep trouble and that all the lockdowns, travel bans, cancellations of everything being justified. My respect for this is growing as I become more educated. I was supposed to go to Greece on Monday. I was bummed out but I reminded myself that this is not about me. 

Stay safe, everyone. 

-EJ

Link to PDF



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.


Intravenous Fluid Lecture: Citations

I have been missing for a few weeks as I am putting the finishing touches on my lectures that are due on the 15th of this month. The amount of time and effort necessary to write a CME lecture is insane. I've written 7 of them in this last year. Voluntarily, of course. I'm not complaining. For my intravenous fluid lecture, I have cited 43 different articles listed below. I have attempted to cite these articles as well as I know how to but there will be some inevitable errors. If you plan on creating an IVF lecture of your own, this is my gift to you. My only request is that you credit me in some way, shape, or form. Ultimately, I did not write any of these articles. I have to tip my hat to everyone who contributed to the writing of all of these articles. They are the ones who did the leg work and I am ultimately piggybacking on their efforts. 

This lecture discusses the three fluids we use for resuscitation in critically ill patients: 0.9% NaCl, Lactated Ringers, and Plasma-Lyte. I go over the history of the three fluids, and also break down the contents of these fluids, based on the data on how they affect our patients and our organs, then present the relevant data on how these data changes outcomes in our critically ill patients. The reason why this is a controversial topic is because most clinicians use saline because they really do not understand what is in it, nor the effects of it. As I mention in one of my slides, if the FDA had to approve 0.9% NaCl today, chances are that it would not be approved. 

I am sorting out how to provide you all with this lecture, youtube or some other medium. The issue is that youtube has a thing for demonetizing my videos the moment I say the words "mortality", "death" and others. I do earn some income from you all visiting my website, eddyjoemd.com to check out the links and download the articles I share. Thank you all for your support! 

-EJ

Citations:


Lobo DN, Stanga Z, Aloysius MM, et al. Effect of volume loading with 1 liter intravenous infusions of 0.9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: a randomized, three-way crossover study in healthy volunteers. Crit Care Med. 2010;38(2):464–470. doi:10.1097/CCM.0b013e3181bc80f1

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Ragaller MJ, Theilen H, Koch T. Volume replacement in critically ill patients with acute renal failure. J Am Soc Nephrol. 2001;12 Suppl 17:S33–S39.

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Bark BP, Persson J, Grände PO. Importance of the infusion rate for the plasma expanding effect of 5% albumin, 6% HES 130/0.4, 4% gelatin, and 0.9% NaCl in the septic rat. Crit Care Med. 2013;41(3):857–866. doi:10.1097/CCM.0b013e318274157e

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Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr. 2001;20(2):125–130. doi:10.1054/clnu.2000.0154

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Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008;27(2):179–188. doi:10.1016/j.clnu.2008.01.008

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Lewins, Robert. Injection of Saline Solutions into the Veins. (1832). The Boston Medical and Surgical Journal, 6(24), 373–375.


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Hartmann AF, Senn MJ. STUDIES IN THE METABOLISM OF SODIUM r-LACTATE. II. RESPONSE OF HUMAN SUBJECTS WITH ACIDOSIS TO THE INTRAVENOUS INJECTION OF SODIUM r-LACTATE. J Clin Invest. 1932;11(2):337–344. doi:10.1172/JCI100415

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Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

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Rizoli S. PlasmaLyte. J Trauma. 2011;70(5 Suppl):S17–S18. doi:10.1097/TA.0b013e31821a4d89

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Brown RM, Wang L, Coston TD, et al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019;200(12):1487–1495. doi:10.1164/rccm.201903-0557OC

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Li H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181–187. doi:10.1631/jzus.B1500201

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Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Invest. 1983;71(3):726–735. doi:10.1172/jci110820

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Quilley CP, Lin YS, McGiff JC. Chloride anion concentration as a determinant of renal vascular responsiveness to vasoconstrictor agents. Br J Pharmacol. 1993;108(1):106–110. doi:10.1111/j.1476-5381.1993.tb13447.x

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Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers [published correction appears in Ann Surg. 2013 Dec;258(6):1118]. Ann Surg. 2012;256(1):18–24. doi:10.1097/SLA.0b013e318256be72

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McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg. 2013;117(2):412–421. doi:10.1213/ANE.0b013e318293d81e

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Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369(13):1243–1251. doi:10.1056/NEJMra1208627

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Noritomi DT, Soriano FG, Kellum JA, et al. Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med. 2009;37(10):2733–2739. doi:10.1097/ccm.0b013e3181a59165

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Neyra JA, Canepa-Escaro F, Li X, et al. Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients. Crit Care Med. 2015;43(9):1938–1944. doi:10.1097/CCM.0000000000001161

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Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care. 2016;20(1):315. Published 2016 Oct 6. doi:10.1186/s13054-016-1499-7

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Modi, MP. A comparative study of impact of infusion of Ringer's Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation.Saudi J Kidney Dis Transpl. 2012 Jan;23(1):135-7.


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Khajavi MR, Etezadi F, Moharari RS, et al. Effects of normal saline vs. lactated ringer's during renal transplantation. Ren Fail. 2008;30(5):535–539. doi:10.1080/08860220802064770

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Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient. Surg Clin North Am. 2012;92(2):189–vii. doi:10.1016/j.suc.2012.01.004

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Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88(10):1127–1140. doi:10.1016/j.mayocp.2013.06.012

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Ichai C, Orban JC, Fontaine E. Sodium lactate for fluid resuscitation: the preferred solution for the coming decades?. Crit Care. 2014;18(4):163. Published 2014 Jul 7. doi:10.1186/cc13973

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Farkas, Josh. “Three myths about Plasmalyte, Normosol, and LR” https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/\.1/26/15


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Nalos M, Leverve XM, Huang SJ, Weisbrodt L, Parkin R, Seppelt IM, Ting I, Mclean AS: Half-molar sodium lactate infusion improves cardiac performance in acute heart failure: a pilot randomized controlled clinical trial. Crit Care 2014, 18:R48.


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Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

Link to Abstract


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Spriet I, Lagrou K, Maertens J, Willems L, Wilmer A, Wauters J. Plasmalyte: No Longer a Culprit in Causing False-Positive Galactomannan Test Results. J Clin Microbiol. 2016;54(3):795–797. doi:10.1128/JCM.02813-15

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Stocker RA. "Normal" Saline and Co: What Is Normal?. Crit Care Med. 2016;44(12):2282–2283. doi:10.1097/CCM.0000000000002030

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Zampieri FG, Ranzani OT, Azevedo LC, Martins ID, Kellum JA, Libório AB. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. Crit Care Med. 2016;44(12):2163–2170. doi:10.1097/CCM.0000000000001948

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Shaw AD, Bagshaw SM, Goldstein SL, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012;255(5):821–829. doi:10.1097/SLA.0b013e31825074f5

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Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. Crit Care. 2015;19(1):286. Published 2015 Aug 28. doi:10.1186/s13054-015-1011-9

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Ince C, Groeneveld AB. The case for 0.9% NaCl: is the undefendable, defensible?. Kidney Int. 2014;86(6):1087–1095. doi:10.1038/ki.2014.193

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Hammond NE, Taylor C, Saxena M, et al. Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013. Intensive Care Med. 2015;41(9):1611–1619. doi:10.1007/s00134-015-3878-y

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Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011;29(6):670–674. doi:10.1016/j.ajem.2010.02.004

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McFarlane C, Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia. 1994;49(9):779–781. doi:10.1111/j.1365-2044.1994.tb04450.x

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Young JB, Utter GH, Schermer CR, et al. Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial. Ann Surg. 2014;259(2):255–262. doi:10.1097/SLA.0b013e318295feba

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Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial [published correction appears in JAMA. 2015 Dec 15;314(23):2570]. JAMA. 2015;314(16):1701–1710. doi:10.1001/jama.2015.12334

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Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018;378(9):819–828. doi:10.1056/NEJMoa1711586

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Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

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Young PJ. Balanced Crystalloids or 0.9% Saline in Sepsis. Beyond Reasonable Doubt?. Am J Respir Crit Care Med. 2019;200(12):1456–1458. doi:10.1164/rccm.201908-1669ED

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Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.