Showing posts with label ards. Show all posts
Showing posts with label ards. Show all posts

Friday, March 27, 2020

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.

Saturday, February 29, 2020

Prone Positioning for ARDS

I am a huge fan of proning patients who are in ARDS. At one point or another I'll cover the data behind proning like the PROSEVA trial (no time today or until at least June). There are a variety of ways to prone patients which reflect the disposable income of the facilities where you work and train. At the 3 institutions were I have worked and the others where I have done moonlighting shifts, we've all used some good ol' fashioned muscles and coordination.

The PDF quoted and linked here was published in December 2019 and is usually very key during flu season. I am not going to comment about the coronavirus but these patients are developing an ARDS-like syndrome where proning may work. I haven't seen any data, though. That being said, having the ability to prone patients and do it well could potentially save lives.

In the paper, they cover pretty much everything I would want them to in a document like this that's beneficial to all. They even discuss chest compressions and defibrillation in these patients, something we all fear.

The PDF is completely free and a direct link. I need to find out the citation for this bad boy. The authors did a great job and a big hat tip to them. There's a really nice safety checklist and nursing checklist included. 

How do you all prone at your institution?

Do you not prone at your shop because of fear of the tube coming out?


Have you ever had to perform CPR on a proned patient?




Link to FULL FREE GUIDELINES


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, February 13, 2020

Dexamethasone in ARDS

This is a big impactful study. I'm happy it came out, really happy. To start off a big hat tip to my colleagues in España who put this together. ARDS sucks. It's a b-word to treat and patients spend a frustratingly long time to come off of the vent. Mortality rates are high. Morbidity rates are through the roof. Cost burden to the healthcare system is insane. The repercussions are unquantifiable. Many of these people never even return to work.

In my practice, when I have a patient with ARDS, I make sure to treat the underlying cause, protect their lungs with the vent, keep them as dry as humanly possible, and provide them with 4 days of vitamin C, hydrocortisone, and thiamine. The CITRIS-ALI study providing vitamin C showed a decrease in mortality in this population, less time in the ICU, and less time in the hospital (albeit with many caveats to that study). There's bench research that shows how vitamin C and corticosteroids are synergistic in preventing and repairing lipopolysaccharide-induced pulmonary endothelial barrier dysfunction. But we never had good data regarding giving these patients steroids to begin with. In theory it made sense, but we needed more help. We were simply doing our best and shrugging our shoulders in many of these cases.

Enter the DEXA-ARDS trial. They randomized patients with moderate to severe ARDS to either get dexamethasone or placebo. Note that they give the first dose immediately after randomization, something that they waited 12+ hours to do in the VITAMINS trial. I digress. Not bitter. Okay I'm bitter. Nonetheless, the pts who got steroids did better. They came off the vent quicker and had fewer deaths. Both statistically significant. One of the key takeaways regarding the vent free days is that we start thinking to trach pts around day 10-14. The dexamethasone group got off the vent around day 14. The control group around day 20. How many trachs were spared and the morbidity that comes with that? It's not specified in the article but I'm curious. Another key piece is the fact that there was no increase in side effects of the steroids.

Ultimately this trial is changing my practice. I was perhaps stopping steroids too early in the past.

-EJ



Villar J, Ferrando C, Martínez D et al. Dexamethasone treatment for acute respiratory distress syndrome: a mutlicentre, randomised controlled trial. Lancet Respir Med. 2020; (published online Feb 7.)

Link to Article (NOT FREE boooooo!)

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, October 1, 2019

ARDS and Vitamin C/Ascorbic Acid: CITRIS-ALI

Here's my bias before I even read the article. I want to see a positive response in providing Vitamin C/ascorbic acid in patients who have Acute Respiratory Distress Syndrome. Why? Because I want me patients to do better with treatments that are inexpensive and easy to manufacture rather than the latest immunologic that ends in -mab and costs tens of thousands of dollars. If before you read this summary, you already think that Vitamin C is a bunch of bullpoop, you need some deep reflections in the mirror. You SHOULD want it to work. Now whether it does or doesn't is different and that's where the data comes in to play.

Ultimately, I'm sure I am going to write far more than what IG will allow me to write do you're more than likely going to have to go to my blog to read my thoughts.

The Study Drugs
Before we even get started, we need to look at the study drugs, or lack thereof. The cocktail that was used in the Marik trial that was monumental in finding a mortality benefit in sepsis included ascorbic acid at 1.5gm q6, thiamine 200mg, and steroids. There is a rationale as to why these three go together that Dr. Marik explains far better than I could ever explain. The three are necessary today. Heck, even Gianfranco Meduri has been using steroids for ARDS for years and it's not part of this study. Red flag number one. Not hating on the authors, I am just saying. Haven't finished reading on it yet. Reserve the right to change my mind. In fact, a quick search shows there's no mention of the word "thiamine" in the entire paper.

Outcomes
The primary outcome was modified sofa scores at 96 hours and biomarkers.
I am not going to go over the secondary outcomes but there are 46 of them. They're covering ALL the bases! Good job.

They enrolled 167 patients. This is remarkable that they were able to enroll this many patients in these 7 centers from 9/14 until 11/17.

Results
Let's talk results. That's why you're here. Are you going to start giving vitamin C to your patients with ARDS, yes or no?

Primary outcome: mSOFA and biomarkers: NO DIFFERENCE.
Secondary outcomes: 43 of 46 had NO DIFFERENCE.

But here is the kicker. The three secondary outcomes that had a difference are pretty important.
1. All-cause mortality (p=0.03). 46.3% in the placebo group vs. 29.8% in the Vitamin C group
2. ICU-free days (p=0.03). Patients were transferred out of the ICU faster in the Vitamin C group
3. Hospital-free days (p=0.04) 22.6 in the vitamin C group vs 15.5 in the placebo

Think of all the money that could be saved by this inexpensive vitamin in shortening time in the hospital. $6 a dose, if I'm not mistaken.

No difference in the biomarkers? Well, this may be my off-kilter idea but maybe we are looking or do not full understand our biomarkers.

There were NO adverse effects that occurred during the trial! I've had many people talk about kidney stones, renal dysfunction, terrible side effects of vitamin C. Well, there were none.

Now, there are many limitations in this study. The authors admit to that full and well. Physicians like myself who are on the pro-vitamin C side will interpret the data the way I just did. Those who are contrarians on the matter will be able to look at the numbers and interpret it differently. They will point out all the flaws in the study and throw the findings of the endpoints in the trash. I may be completely off base with my interpretation of these results, but I want to do EVERYTHING that's reasonable to take care of my patients. And if that means spending $24 a day on Vitamin C, I will do it.

If you were the patients on the ventilator with ARDS, would you want the doctor treating you to give you vitamin C?

-EJ




Link to Abstract

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, July 6, 2019

Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome

Link to Abstract

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.

Saturday, June 29, 2019

Noninvasive Ventilation in Acute Hypoxemic Respiratory Failure



Link to Abstract

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, June 26, 2019

Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome



Link to Abstract

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, June 23, 2019

ARDS: Formal Guidelines










Link to Abstract

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.

Friday, June 21, 2019

Helmet vs Face Mask NIV for ARDS

I originally posted this article on 6/21/19 while preparing my NIV/BiPAP lecture. During that process, I learned and shared on IG about using a helmet rather than a mask for NIV (non-invasive ventilation). Looking at the footage that has been coming out of Italy and other parts of the world, you can catch a glimpse of their pumps, ventilators, and in the case of this post, the fact that many institutions are using the helmets.

Why are these places using helmets instead of face masks and what does the data say?

The study I am referring to was published in JAMA in 2016 and they compared utilizing a face mask vs a helmet setup in patients with ARDS. The study was actually stopped early because the data was so good. They were trying to get to 206 patients but stopped at 83.

The authors found that patients who wore the helmet were intubated less frequently, 18.2% vs. 61.5%, had more ventilator free days, a shorter length of stay in the ICU, and lower both in-hospital mortality and 90 day mortality. Patients were also on NIV with the helmet for a shorter period of time utilizing less PEEP, less pressure support, and required a lower FiO2.

Could the helmet be a tool to help out to minimize the need for intubation and mechanical ventilation? Does anyone here have experience with the helmet setup? This study was created in Chicago, I'm sure there's has to be someone around here who was at that institution while this study was being performed.

-EJ

Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2016;315(22):2435–2441. doi:10.1001/jama.2016.6338

Link to Article

Link to FULL FREE PDF

Link to PDF (Backup)





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.