Discover and read the best of Twitter Threads about #A2FBundle

Most recents (24)

Simulation in ICU - #EmpathyšŸ‘‡

A doctor volunteer trying to understand what itā€™s like to be tied down & sedated.

More & more we must dive down into what we do to others to understand their experiences

To improve our careā€¦#A2Fbundle
Asking:

ā€œWhat is causing their agitation? How can you respond to it? Do they have contraindications to mobility? How do you start?ā€
She @DaytonICU gives complex scenarios & walks us through the process of asking, ā€œWhat is their RASS? Why are we concerned about delirium? What are their risk factors for ICUAW? Why are we concerned about ICUAW? Do they have an indication for sedation?ā€

ā€œNow what do you doā‰ļøā€
Read 4 tweets
1/šŸ§µCOVID & Death: #JAMA
Ā 
šŸ“N=1,846 pneumonia patients w versus w/out COVID
šŸ“COVID didnā€™t ā€œinventā€ a new lung disease
šŸ“We freaked out saying vents needed to be so different
šŸ“Docs erred as we deviated from our evidence-based

Why should YOU care?
Ā 
bit.ly/3QIp2Tl
2/ COVID is a very long pneumonia process, but we exacerbated itā€¦

This graph shows that Death occurs similarly, but COVID #death takes longer (10 vs. 7 days).

Time to discharge alive is twice as long (10 vs. 5 days) in COVID vs non-COVID pneumonia.

We caused a lot of this šŸ˜ž
3/ Letā€™s breaks outcomes down by O2 levelsā€¦
Ā 
At 90 days, death rates were same in COVID & non-COVID pneumonia for patients w moderate & severe low O2 levels

COVID was NOT a predictor of more death or liberation from the vent or hospital (after matching & multivariable models)
Read 8 tweets
1/šŸ§µ Imagine Deliriumā€¦#COVID or notā€¦

ā€œHer mind tottered & slithered again, broke from its foundation & spun like a cast wheel in a ditchā€¦She sank through deeps & deeps of darknessā€¦

Katherine A. Porter, ā€œPale Horse, Pale Riderā€ on her delirium in 1918 Spanish flu pandemic
2/ Until she lay like a stone at the bottom of lifeā€¦a stench of corruption filled her nostrilsā€¦she opened
her eyes & saw pale light through a coarse cloth
over her face, knew the smell of death was in her
body & struggled to lift her hand.ā€

Spare your patient. How?
#A2Fbundle
3/fin
This investigation of 13 studies found that earlier mobilization of ICU patients reduced the risk of #delirium by 47% and by nearly 2 days in total duration.

To do this we must stop sedation & have patients safely able to participate in walking.

bit.ly/3gTYvVk
Read 3 tweets
1/šŸ§µWhat do ICU survivors tell me about PICSā€¦(post intensive care syndrome)ā‰ļø

Former ICU patient: ā€œIā€™m angry. Iā€™m furious because the doctors who injured me arenā€™t willing to help me recover.ā€

Is this fair?

I think so.

Why?

Read onā€¦(perm to share)
2/ I just got off the phone w a patient who has had PICS for 12 years since nearly dying in the ICU. His story is included in #EDDBā€¦he granted permission to share some thoughts today that I think are eye openingā€¦in terms of how poorly weā€™re doing w Chronic Disease management
3/ people who never had PTSD before critical illness, leave with inexplicable experiences of road rage, rejecting their spouse, acting in ways that are so foreign to them that they donā€™t recognize themselves.

They also have tremendous problems with lack of self worth becauseā€¦
Read 7 tweets
1/šŸ§µšŸŽ„ How do ā€œDominoes of lifeā€ fall in critical illnessā‰ļø

A pt arrives awake & talking but vomiting. In just 8 hrs he nearly dies of sepsis šŸ¤Æ

Lung & kidney failure, heart attack, coma.

How can this happen & can we save him?

ThisšŸ§µcan help us understand the ā€œarc of illnessā€
2/ His disease is Ascending Cholangitis

A gall stone lands in his common bile duct

šŸ“Pain & vomiting
šŸ“Heā€™s admitted to the ICU
šŸ“GI performs an ERCP to place a stent, bypass the stone, drain pus & control the source of sepsis
šŸ“Add fluids & antibiotics
šŸ“But he gets worse
Why?
3/ We bypassed the septic source (stone) & drain the pus, but dominoes were already falling.

Bacteria had gotten into his blood.

Too much inflammation & capillary blood clotting occurred, just like in COVID.

What happens when ā€œcellularā€ dominoes start to fall uncontrollably?
Read 11 tweets
So the problem of MD shortages is so very real. ā¤ļø the timely article, agree with so much of it, but only partial solutions discussed here. A thread for some more color to this šŸ§µ 1/8

time.com/6199666/physicā€¦
As the MD numbers donā€™t add up from supply-demand curves, we started a ā€œfellowship/residencyā€ for NP/PAs in critical care & then pulmonary @RKleinpell is a pioneer in this space.

ncbi.nlm.nih.gov/pmc/articles/Pā€¦
At some point #Telemedicine has to be considered to leverage technology & scale expertise. @ADVISSOR_One is trying to lead this on a national scale

liebertpub.com/doi/pdf/10.108ā€¦
Read 10 tweets
1/šŸ§µ You have a COVID ICU patient on benzos who doesnā€™t respond to needle injection of local anesthetic do to sedatives.
Ā 
What depth of sedation do you consider this? (it was a CME question just now)
2/ The answer is GENERAL ANESTHESIA, which of course makes sense.

If a person is so deep that he/she doesnā€™t respond to getting stuck by a needle and the pain of lidocaine injection, that is general!

Why am I writing about this?
3/ Anyone working in the ICU this past few years of #COVID #PANDEMIC is seeing this depth of sedation on a regular basis.

We had almost gotten rid of this by 2019. Then COVID undid progress.

People now think this is normal for some reason.

It is NOT normal.

It is not OK.
Read 9 tweets
1/šŸ§µ Why is COVID hospitalization like 2X sticks of dynamite šŸ§Ø?
Ā 
A thread on the ICU portionā€¦ #PICS + #LongCOVID.
Ā 
Prevent this w 3 steps:
šŸ“ŒAvoid #COVID by Vax & Mask
šŸ“ŒAvoid severe COVID by Paxlovid & Monoclonal Ab
šŸ“ŒšŸ‘‡ read here about PICS & how to reduce injury in the ICU
2/ Hereā€™s what you must know if you get too sick & land in an ICU.

History Lesson šŸ“
In the past, too many decisions in #CriticalCare were guided by fear. We oversedated patients for too long out of worry they might self-extubate & pull off restraints.

Thatā€™s happening again šŸ¤®
3/ We kept patients immobilized due to an overly conservative approach to fall prevention that precluded us from attempting to walk them early. We kept families away from patients, treating loved ones as visitors rather than members of the healing plan.

Thatā€™s happening again.
Read 10 tweets
1/šŸ§µšŸŽ„ A young mom suffering #COVID. Her husband is scared.

We need to prevent serious long-term complications. Her new normal will likely include PTSD, Dementia, Depression & severe physical disability. (shown w Perm)

Not so ā€œmildā€ āž”ļø Do you want this?

#vaccinate
#LongCOVID
2/ what you need to know about ICUs, #PICS and #LongCOVID prevention:

I wrote this @thedailybeast piecešŸ‘‡ to help empower you as patients & families. Itā€™ll tell you what you need to know & ask your team for amid the chaos and confusion.

Thereā€™s moreā€¦

bit.ly/3DhC6Xe
3/ This patient on 100% O2 and high-dose propofol & fentanyl did not need both agents. When able, we try to avoid prop & benzos. We stopped Prop, continued Fentanyl & added dexmedetomidine because itā€™s shorter acting & wonā€™t build up so much in her brain.

This is the #A2Fbundle.
Read 7 tweets
1/šŸ§µROADMAP: What should you know before someone you ā¤ļø lands in the ICU? @TheDailyBeast
Ā 
I whittle down IMPORTANT PEARLS & pro-tips about how to approach acute #COVID19 and non-COVID care to avoid life-changing disabilities later.
šŸ‘‡

bit.ly/3oRVZRt
2/ #COVID pts return home after cutting-edge medical care but many survivors are now living with massive & likely life-long disabilities that include dementia, PTSD, depression & major weakness from muscle and nerve disease. #PICS #LongCOVID

3/ These two entities, #LongCOVID and #PICS, have many overlapping forms of suffering that must be acknowledged by healthcare professionals and loved one for survivors to feel validated & heard. People throughout society in all our communities will benefit.
Read 21 tweets
1/šŸ§µ People ask me, ā€œWhatā€™s the main purpose of treating #COVID ICU pts with the #A2Fbundle? (a daily safety checklist of ā¬‡ļø sedation & ā¬†ļø mobilization). Itā€™s to prevent #PICS related dementia, PTSD, depression & reduce suffering in #LongCOVID.

HOW? What is the philosophy?
2/ For patients itā€™s about magnifying their #dignity and self-worth by liberating them sooner from us (our treatments that put them through a depersonalization chamber). For HCWs, itā€™s about purity of service, avoiding hypocrisy, and better self-sacrifice for our patients.
3/ Waking people up and walking them w family at their side in PPE (even inside a room if #COVID+) allows them to feel alive again. Repersonalized! Human. Seen. Drives away #delirium & #brainfog. Wouldnā€™t you want this?
Read 8 tweets
1/šŸ§µšŸŽ„ Hard-Won #Wisdom from the wife of a #LongCovid patient >140 days into hospitalization.

You need to hear her 2 messages:
1. ā€œWhat I can tell you is Iā€™ve never given up #hope. To make it to tomorrow, we have to make it through today first.ā€

HUMILITY ā¤ļøā€šŸ©¹ IS HER MEDICINE
2/ When things are acute, like in this video of her husband when he was 1st in the ICU, we tend to think our task list is all technological. Iā€™m guilty of this. And Iā€™ve caused ā¬†ļø suffering because of my tunnel vision.

3/šŸŽ„ Point #2 from my pts wife:
ā€œHeā€™s not gonna get better next week or next month. #COVID takes a LONG time. Our lives are forever changed. Expect setbacks & be your loved oneā€™s advocate!ā€

NOW she & he are convinced of the importance of #Vaccination & masking. Learn from them!
Read 15 tweets
1/šŸ§µWhat is Testimonial Injustice in medicine? Itā€™s Silencing ptsā€¦

@crageshri tells her story & itā€™s brave & important. In #COVID, I have silenced pts by giving too much sedation to ventilated pts. I was wrong.

At every opportunity, I must amplify my ptsā€™ voices!

#A2Fbundle
2/ Dr. Rageshri writes:
Testimonial injustice can occur when a personā€™s voice or knowledge is discounted or dismissed due to bias from the listener about their social identityā€¦
3/ Itā€™s a type of silencing called ā€œtestimonial smotheringā€. This is a form of self-censoring, where silence or withholding testimony is preferable to the psychological trauma of being dismissed and disbelieved.
Read 5 tweets
1/šŸ§µ Iā€™d like to think as a medical community that we have changed & no longer discharge people w/out appropriate follow-up, but just last week I met a #COVID19 survivor who was discharged from the ICU simply to follow up w his primary care physician.

#LongCOVID #PICS #A2FBundle
2/ He couldnā€™t return to his job, was fired & had no income for his family. That resulted in him not having enough money for medications, gas, or bills. He missed his doctorā€™s appointment, his electricity was turned off, so he is unable to apply online for disability. šŸ˜¤
3/ The cycle continues. I usually see these pts when they get septic again & end up back in my ICU on life support.
Read 4 tweets
1/ šŸ§µWisdom in Medicine
Ā 
Whatā€™s going on here? And why itā€™s key in #COVID19
Ā 
Itā€™s quite simple: we finally had the #wisdom to ask Mr. D the right question! He and his wife encouraged us to use this picture to teach what we learned.
Ā 
#PalliativeCare #MedTwitter #NurseTwitter
2/ What we learned was to switch the preposition!
Ā 
Mr. D was a pre-#COVID patient. On this day, he was taken off the vent after a MONTH. The incessant mantra had been, ā€œWhatā€™s the matter WITH Mr. D?ā€ He was surprised when we asked, ā€œWhat matters TO you, Mr. D?ā€
3/ He has a tracheostomy, as you can see. We insert this airway through the neck to improve #comfort when someone is on a vent well beyond 10 days. Heā€™s more comfortable because he no longer has a tube in his mouth. We used a program called the #A2Fbundle to reduce his #delirium.
Read 13 tweets
1/šŸ§µ#COVID19 Compassion

Our patient wants to live 3 days to see his grandson graduate. He has #COVID19 pneumonia & is extremely short of breath. Heā€™s chosen NOT to go on a ventilator & is on 100% O2 HiFlow Canula. Heā€™s afraid of tight-fitting a bipap mask.

#PalliativeCare
2/ The intern said, ā€œI never saw a patient whose respiratory rate was twice his oxygen saturation!ā€ Yep, last night his O2 sats dropped to 30% and he was breathing 60 times a minute! By morning he was 85% sat and RR was 28. Better but tenuous.

#TipsForNewDocs #MedStudentTwitter
3/ All of this raises some complicated ethical + treatment questions that Iā€™d like to cover. We addressed this on rounds several times this week & at times it got a bit heated. His #nurse said she noticed herself flushed, mad, and heart rate >130ā€¦why?
Read 13 tweets
1/šŸ§µThis figure from CHEST on early tracheostomy in #COVID19 pts is helpful for 2 reasons: it points out different ways of care. Read the BLUE circles clockwise & then switch to OUTER RED ARROWS clockwise again. Clear and True.

bit.ly/3w3DXfc

#medtwitter #nursetwitter Image
2/ The #COVID pt with ARDS + Sepsis on a ventilator is TOO often subjected to TONS of sedation, which adds brain injury, immobilization & development of physical disability. NEW DISEASES added to the original problem. We call this Post-Intensive Care Syndrome #PICS. Image
3/ Early tracheostomy around day 10 can help (not always!) as outlined in the RED ARROWS. The goal is to lessen the added injury by waking people up, getting them out of bed and early mobilization plus talking with family. This is done via the #A2Fbundle. @SCCM Image
Read 4 tweets
1/ Do data support pt trial off sedation for ā€œSATā€ when pt is comfortable on current dose? Yes
Ā 
Shared w permission:
ā€œDr. Ely, yesterday our ICU #nurses went over #A2Fbundle in Epic for implementation. Do you recommend SAT at RASS Goal of RASS -1 to +1?
#medtwitter #criticalcare
2/ Excellent #Nurse added:

ā€œWe are currently not doing SAT (Spontaneous Awakening Trial) but keeping ptā€™s RASS -1 to +1.Ā  Just want to make sure we are interpreting #A2Fbundle correctly.ā€
Ā 
#TipsForNewDocs
#medstudenttwitter #COVID19 #pandemic
3/ my Answers:

Great questions. I donā€™t think +1 (anxiety) is ever a good goal but 0 to -1 is a šŸ‘ default target RASS if we acknowledge there are times when sedation target should acceptably be set as deep as -3/-4 in bad #ARDS or -5 transiently when pt requires paralytics.
Read 8 tweets
1/ Scientific Discovery: time & patience
Ā 
Be patient in science. 25 yrs ago, I & others felt we were harming ICU patients by deep sedation & immobility. Our goal: PROVE IT & change culture in #criticalcare.
Ā 
How did we start?

#medtwitter #A2Fbundle #nursetwitter
2/ Scientific Discovery: takes time

There werenā€™t tools šŸ˜¤Reluctantly, I had to go ā€œbackwardsā€ to validate CAM-ICU & RASS (@JAMA_current X3). A DECADE later we produced studies lightening sedation (MENDS/ABC trials JAMA/@TheLancet). Be patient!

#academictwitter #ScienceTwitter
3/ Scientific Discovery: patience
Ā 
Give yourself space to be creative! Science takes time & Data must lead you. All our 1st grants & papers were rejected for 5 YEARS. NIH said: #Delirium in ICU is not a viable topic or a ā€œthing.ā€ Go away. Persistence paid off for patient safety.
Read 5 tweets
Green Urine: #NEJM
Ā 
....will be seen in #COVID ā€“ Why? Massive use of Propofol. While Green Urine is Benign, effects of prolonged over-sedation & immobilization ++ #DELIRIUM are not šŸ˜¤ Wake them up & get out of bed. Start w/SATā€¦#A2Fbundle & #PICS

#medtwitter #nursetwitter
1/ re: SATs to avoid over-sedation in #COVID19 pts, Thx @phanton_icu for Protocol Blindness caution & @Nitkjain reminder ā€œEasier said than done.ā€ Iā€™ve been pondering your comments all day & think them ripe for further conversation on #A2Fbundle

#medtwitter #pulmcc #nursetwitter
2/ Remember, protocols like #A2Fbundle are guides & not ā€œ1-shoe-fits-all pts.ā€ Correct, we must deviate when needed. However, these 6 principles (ABCDEF) are derived from 35 NEJM, JAMA, Lancet papers +400 others & now >25,000 pts of data. Not chump change.
bit.ly/2JwVA4E
Read 10 tweets
1/ ICU #diaries for Good #Death:
Ā 
Especially at EOL, ICU #Diary is part of #A2Fbundle. My pt w/ home-hospice told me details recorded in #ICU by #nurse allowed her to decipher cryptic #delirium memories she was struggling with.

bit.ly/36DOtk3

#medtwitter #meded
2/ Then she told me of hours spent reading big-hearted comments others had written in her ICU diary, making her realize how much her life meant to others. It was a priceless gift to her at a critical juncture in what had a time of deep poverty in her life. #PalliativeCare
3/ ICU Diaries give family members at bedside a practical way of helping w/ loved oneā€™s care & can help channel their worries in a focused way.
#criticalcare #pulmcc
Read 7 tweets
1/ When I play the #criticalcare movie šŸŽ„ of me as an intern or resident back in my head, I see myself as much too robotic šŸ¤– with my patients, as if plugging in kitchen appliances.

#medtwitter #meded #tipsfornewdocs #medstudenttwitter #nurse #pulmcc #COVID19
2/ The nurse would slip a Foley catheter up his urethra into his bladder. Iā€™d go to the stockroom to get all the materials to slide a plastic endotracheal tube down his trachea to become command-central for his breathing on the ventilator.
3/ Next, Iā€™d methodically place a Swan-Ganz catheter by serial insertion of a needle first, then a wire through the needle, next a dilator over the wire, and finally the catheter itself down into his great vessels and heart. And start the ā€˜pressors.
Read 6 tweets
1/ In #COVID19, we must learn from #BRAIN masters Engel & Romano, who described #DELIRIUM to #DEMENTIA relationship in the 1950s! Here are my TOP 10 CLASSIC quotes from their famous 1959 article:
bit.ly/2SePA1a
Ā 
#medtwitter #meded #tipsfornewdocs #neurology #geriatrics Image
2/ The problem of delirium is far from an academic one. Not only does the presence of #delirium often complicate and render more difficult the treatment of a serious illness, but also it carries the serious possibility of permanent irreversible brain damage.
Ā 
#dementia #COVID
3/ The deficiencies in the education of many physicians ill equip them to recognize any but the most flagrant examples of delirium.
Ā 
#A2Fbundle #tipsforolddocs
Read 12 tweets
1/ Women in Critical Care:

šŸ‘ Just recorded #ISICEM roundtable w @frubulotta @ElisabethWaele @FlaviaSepsis & Dr. Juffermans. šŸŽ„ šŸæ on Sept 16th.

Letā€™s eliminate prejudice based on gender, sexual pref & color. Here is a Bakerā€™s Dozen of Women ICU Leaders!

#heforshe #medtwitter Image
2/ The first woman leader in Critical Care I discussed was Dr. Christina Jones from UK. She is a Biochemist, Nurse, Masters Social Work, PhD in Psychotherapy.

šŸ‘ŠMother of ICU Support Groups & ICU Diaries. As an expert, she shaped our field!

#sccm #esicm #pulmcc #ICUrehap Image
3/ 2nd world leader in Crit Care presented was Dr. Deborah Cook, from McMaster Univ in Canada. Seminal trials in Ulcer Proph, Bioethics, CCCTG trials, and now edifying us about how to provide healing in the dying process through her 3-Wishes Project.
#endoflife #palliativecare Image
Read 8 tweets

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