Discover and read the best of Twitter Threads about #A2Fbundle

Most recents (24)

1/🧵 You have a COVID ICU patient on benzos who doesn’t respond to needle injection of local anesthetic do to sedatives.
 
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 doesn’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/🧵 Why is COVID hospitalization like 2X sticks of dynamite 🧨?
 
A thread on the ICU portion… #PICS + #LongCOVID.
 
Prevent this w 3 steps:
📌Avoid #COVID by Vax & Mask
📌Avoid severe COVID by Paxlovid & Monoclonal Ab
📌👇 read here about PICS & how to reduce injury in the ICU
2/ Here’s what you must know if you get too sick & land in an ICU.

History Lesson 📝
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.

That’s happening again 🤮
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.

That’s happening again.
Read 10 tweets
1/🧵🎥 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 “mild” ➡️ Do you want this?

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

I wrote this @thedailybeast piece👇 to help empower you as patients & families. It’ll tell you what you need to know & ask your team for amid the chaos and confusion.

There’s more…

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 it’s shorter acting & won’t build up so much in her brain.

This is the #A2Fbundle.
Read 7 tweets
1/🧵ROADMAP: What should you know before someone you ❤️ lands in the ICU? @TheDailyBeast
 
I whittle down IMPORTANT PEARLS & pro-tips about how to approach acute #COVID19 and non-COVID care to avoid life-changing disabilities later.
👇

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/🧵 People ask me, “What’s the main purpose of treating #COVID ICU pts with the #A2Fbundle? (a daily safety checklist of ⬇️ sedation & ⬆️ mobilization). It’s to prevent #PICS related dementia, PTSD, depression & reduce suffering in #LongCOVID.

HOW? What is the philosophy?
2/ For patients it’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, it’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. Wouldn’t you want this?
Read 8 tweets
1/🧵🎥 Hard-Won #Wisdom from the wife of a #LongCovid patient >140 days into hospitalization.

You need to hear her 2 messages:
1. “What I can tell you is I’ve never given up #hope. To make it to tomorrow, we have to make it through today first.”

HUMILITY ❤️‍🩹 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. I’m guilty of this. And I’ve caused ⬆️ suffering because of my tunnel vision.

3/🎥 Point #2 from my pts wife:
“He’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 one’s advocate!”

NOW she & he are convinced of the importance of #Vaccination & masking. Learn from them!
Read 15 tweets
1/🧵What is Testimonial Injustice in medicine? It’s Silencing pts…

@crageshri tells her story & it’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 pts’ voices!

#A2Fbundle
2/ Dr. Rageshri writes:
Testimonial injustice can occur when a person’s voice or knowledge is discounted or dismissed due to bias from the listener about their social identity…
3/ It’s a type of silencing called “testimonial smothering”. 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/🧵 I’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 couldn’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 doctor’s appointment, his electricity was turned off, so he is unable to apply online for disability. 😤
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/ 🧵Wisdom in Medicine
 
What’s going on here? And why it’s key in #COVID19
 
It’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.
 
#PalliativeCare #MedTwitter #NurseTwitter
2/ What we learned was to switch the preposition!
 
Mr. D was a pre-#COVID patient. On this day, he was taken off the vent after a MONTH. The incessant mantra had been, “What’s the matter WITH Mr. D?” He was surprised when we asked, “What matters TO you, Mr. D?”
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. He’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/🧵#COVID19 Compassion

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

#PalliativeCare
2/ The intern said, “I never saw a patient whose respiratory rate was twice his oxygen saturation!” 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 I’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 >130…why?
Read 13 tweets
1/🧵This 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 “SAT” when pt is comfortable on current dose? Yes
 
Shared w permission:
“Dr. 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:

“We are currently not doing SAT (Spontaneous Awakening Trial) but keeping pt’s RASS -1 to +1.  Just want to make sure we are interpreting #A2Fbundle correctly.”
 
#TipsForNewDocs
#medstudenttwitter #COVID19 #pandemic
3/ my Answers:

Great questions. I don’t think +1 (anxiety) is ever a good goal but 0 to -1 is a 👍 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
 
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.
 
How did we start?

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

There weren’t tools 😤Reluctantly, I had to go “backwards” 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
 
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 “thing.” Go away. Persistence paid off for patient safety.
Read 5 tweets
Green Urine: #NEJM
 
....will be seen in #COVID – Why? Massive use of Propofol. While Green Urine is Benign, effects of prolonged over-sedation & immobilization ++ #DELIRIUM are not 😤 Wake them up & get out of bed. Start w/SAT…#A2Fbundle & #PICS

#medtwitter #nursetwitter
1/ re: SATs to avoid over-sedation in #COVID19 pts, Thx @phanton_icu for Protocol Blindness caution & @Nitkjain reminder “Easier said than done.” I’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 “1-shoe-fits-all pts.” 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:
 
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 one’s care & can help channel their worries in a focused way.
#criticalcare #pulmcc
Read 7 tweets
1/ When I play the #criticalcare movie 🎥 of me as an intern or resident back in my head, I see myself as much too robotic 🤖 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. I’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, I’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 ‘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
 
#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.
 
#dementia #COVID
3/ The deficiencies in the education of many physicians ill equip them to recognize any but the most flagrant examples of delirium.
 
#A2Fbundle #tipsforolddocs
Read 12 tweets
1/ Women in Critical Care:

👍 Just recorded #ISICEM roundtable w @frubulotta @ElisabethWaele @FlaviaSepsis & Dr. Juffermans. 🎥 🍿 on Sept 16th.

Let’s eliminate prejudice based on gender, sexual pref & color. Here is a Baker’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.

👊Mother 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
1/ #Sedation & #Delirium in #COVID19:

The cornerstone of best sedation practice in #COVID is not a specific drug. It’s about lightening whatever you use to allow the brain to take over again as captain of the body’s ship.

#medtwitter #tipsfornewdocs #medstudenttwitter #pulmcc Image
2/ Personally, & this is a share of my own weakness, it makes a huge difference when my patient is awake & not sedated. Awake patients immediately become humans with real lives beyond the ICU.

#meded #sccm Image
3/ The outer shell of patients changes in my mind’s eye when they are lying in a drug-induced coma - the person becomes disembodied. I am blind to the person, who doesn’t seem to be with her own body. I know this is a defect in my own abilities as a physician.

#tipsforolddocs Image
Read 5 tweets
Brain 🧠 #COVID19: “F__k Covid”

Am I right?! 😅

To help us teach others causes of #Delirium in our pts & reduce suffering & #PICS, I made these two slides. Use today. Spread the word!

#MedTwitter #MedEd #TipsForNewDocs #A2Fbundle #pulmcc ImageImage
Also if anyone is offended by the F-Covid mnemonic please accept my apology. The original I taught in rounds this week was VOC-DIF but my residents quickly suggested I rearrange the letters. TRUE STORY!! 🤣

#MedTwitter #TipsForNewDocs #laughter #pulmcc
Inventors of F-COVID MNEMONIC:

To give credit where credit is due, Alex Wiles @AlexWilesTweets & John Laurenzano were the two #Vanderbilt #medicine residents who rearranged the letters to “fix” this mnemonic! Thanks guys 😘 ImageImage
Read 3 tweets
1/ Mechanism: Lung + Brain Injury in #COVID19:
 
In the ICU w/ #COVID we are dealing w/ SEPSIS & ARDS…most of what goes wrong in the human body when it’s infected with SARS-CoV-2 virus is mediated by…

read on...
 
#medtwitter #medstudenttwitter #pulmcc #tipsfornewdocs #meded
2/ Injury from SARS-CoV-2 virus is mediated by how much swelling (inflammation) and blood flow abnormalities (clotting and bleeding) occur, it’s wise to review what we know about SEPSIS, ARDS, & the BRAIN.
3/ Lung pathology affect parallel disturbances in the brain (& liver) via endotoxin, TNF, hypoxemia, shock & coagulopathy, metabolic derangements, & medical therapy such as the mechanical ventilator itself & sedatives & analgesics.
Read 8 tweets
In this thread, I'm live-tweeting @sgdambrauskas awesome talk for @AKUGlobal series on #COVID19 in #PedsICU

Critically important topic #Zentensivist #ICURehab #BacktoBasics #DoNoHarm
Defining iatrogenic via @sgdambrauskas #PedsICU
Critical Illness is an iatrogenic disorder- @sgdambrauskas highlights an important perspective by John Marshall in @CritCareMed #PedsICU
Read 16 tweets
#COVID19 🧠 ALERT:
Tom Petty’s famous 1998 editorial was prescient & never more important than now as we struggle to adapt ICU care to a long & brutal ARDS w added DENSE delirium. READ 📚 3 HIGHLIGHTS!

👀 attached stream
CHEST: bit.ly/2BTvK78
#MedTwitter #pulmcc ImageImage
“But what I see these days are paralyzed, sedated patients, lying without motion, appearing to be dead, except for the monitors that tell me otherwise.” Petty 1998
“Why have we regressed to these critical care practices?” Petty 1998
Read 4 tweets

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