Discover and read the best of Twitter Threads about #Delirium

Most recents (24)

1/🧵 Imagine Delirium…#COVID or not…

“Her mind tottered & slithered again, broke from its foundation & spun like a cast wheel in a ditch…She sank through deeps & deeps of darkness…

Katherine A. Porter, “Pale Horse, Pale Rider” on her delirium in 1918 Spanish flu pandemic
2/ Until she lay like a stone at the bottom of life…a stench of corruption filled her nostrils…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.”

Spare your patient. How?
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.
Read 3 tweets
1/🧵 Haldol for ICU patients⁉️

📌 Not so fast
📌 Study of N=1000 backs-up our MIND-USA study - full 🧵👇
📌 Haldol doesn’t treat #delirium
📌 Calms pts & can ⬇️ danger
📌 Delirium care is about non-pharm approaches - the Dr. DRE…
2/ Dr. DRE = non-pharmacological approaches to #delirium reduction. Hint - it’s Not about adding drugs.

📍Disease remediation
📍Drug Removal
📍Environment (eye glasses, hearing aids, sleep, light, mobilization)
3/ In this thread👇 I unpack our previously published 2018 placebo controlled randomized trial of typical and atypical antipsychotics.

The MIND-USA study & today’s new ACT-ICU RCT are complementary & should make us unsatisfied w ✍🏻 antipsychotics to treat delirium.
Read 6 tweets
1/🧵🎥 How do “Dominoes of life” fall in critical illness⁉️

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

Lung & kidney failure, heart attack, coma.

How can this happen & can we save him?

This🧵can help us understand the “arc of illness”
2/ His disease is Ascending Cholangitis

A gall stone lands in his common bile duct

📍Pain & vomiting
📍He’s admitted to the ICU
📍GI performs an ERCP to place a stent, bypass the stone, drain pus & control the source of sepsis
📍Add fluids & antibiotics
📍But he gets worse
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 “cellular” dominoes start to fall uncontrollably?
Read 11 tweets
One of the most inspirational people on my Twitter timeline is @Lyndseydunn7.

Now talking here at the @GeriSoc #bgsconf on delirium and how we need to identify it and manage it in the real life situations we see every day.
It’s very impressive to see what Lyndsey and the @NHS_Lothian team have achieved with their programme.

We know what the definition is for #delirium, yet the language used in clinical records is often poor. Well said, @Lyndseydunn7 !

Read 9 tweets
1/🧵 Does Alcohol shrink the brain?
Yes, all liquor can hurt our brains if we drink too much. The disease of Alcoholism, which is NOT the fault of the person afflicted, causes brain injury slowly over time.
A picture is worth 1,000 words. Look below at a diseased brain…
2/ Gray on this CT scan indicates actual brain tissue.

Do you see the black areas pointed out here by RED arrows?

These are called sulci (grooves).

This <40 year old person has VERY large grooves that show the amount of brain tissue as we would see in someone >80 w dementia.
3/ Normally brain grooves are small in young people. See example👇.

When someone gets dementia, s/he can lose actual brain tissue (less gray) and the area fills in with fluid (BLACK - sulci).

SO this is atrophy & manifest in life as memory problems & executive dysfunction.
Read 6 tweets
Part 3 #Illnessdoesntmeanstillness by @SapnaKmd
🔸we have created a culture of immobility
🔸"prolonged bedrest is anatomically and physiologically unsound" JAMA

#SCCM2022 #PedsICU
Goal to change culture
🔸initial cost was multiprofessional investment
🔸"PICU Up" became the common name
🔸Followed AHRQ QI model

#SCCM2022 #PedsICU
Read 12 tweets
1/🧵🎥 “It’s a very bad disease. It can be overcome.”
My #COVID patient tearfully speaks of his BIG DECISION on the ventilator.

This soldier & leukemia survivor made it through 3 weeks on a ventilator. How?
Video shown w his permission “to help others find hope, Doc.”
2/ This immunocompromised man was in massive viral septic shock from COVID.

Huge doses of vasopressors.

Gargantuan levels of O2 & vent pressure to save his life.

Lungs, Kidneys, Heart and Brain all failed.
3/ His wife was there with him daily.

We put up pictures of his kids and pets.

We talked to him about the things he loved every day (even when sedated and seemingly unable to hear us).

Somewhere in all of that, he made a silent decision…
Read 8 tweets
Kudos @RealMilesBerger and team for this study…
I made a brief🧵from my perspective as people keep asking me about these findings (and I love discussing about this topic):
26% of older adults had changes in at least 1 cognitive domain 6 weeks after surgery, not a negligible number. This was unrelated to CSF changes in AD biomarkers and remains unknown what drives this dysfunction in these subjects...
From this same clinical cohort we have shown that resolving lipid mediators and non-resolving inflammation may contribute to changes in cognitive trajectories (or PND) but the sample size was limited in order to be conclusive on these new CSF biomarkers.…
Read 5 tweets
1/🧵Important = Brain Injury in #COVID💥
📍N=251 hospitalized COVID pts had biomarkers of neurodegeneration (dying brain cells).

📍Previously healthy COVID pts had ⬆️er levels than Alzheimer’s pts!

How do we understand this?
Hint: #Vaccinate yourself
2/ These elevated brain biomarkers indicate disease to different types of brain cells (eg, astrocytes, glial cells, neurons) in COVID patients. These were early unvaccinated pandemic patients. Vaccinated people will be less prone. WHY?
3/ There isn’t a ton of brain invasion by COVID. We think most of the 🧠 injury is INDIRECT. Meaning downstream injury from 1. upstream inflammation 2. blood clotting & 3. heavy sedation causing #delirium, which we proved to be a #dementia risk factor!
Read 7 tweets
1/🧵 Sleep for Sick Patients & #LongCOVID

If sleep is so important, why do we wake you up (hourly) in hospital?

Do #LongCOVID pts need MORE rest than they think?

We’re studying this to see if “forcing” hospital quiet times helps people survive & get less #delirium.

Read on…
2/ It makes sense to me that it’s unhealthy to keep waking up people who are trying to get rest & heal.

If the body needs 7 hours #sleep a night when NOT sick (see 🧵 in tweet above), is it anti-medicine to prevent us from even more sleep when so much repair is needed? Image
3/ @fi_lowenstein & @itsbodypolitic wrote a wonderful piece about how she “rested herself” to health when suffering #LongCOVID.

I tell my COVID survivors @CIBScenter, “However much sleep/rest you think you need, double it.”
Read 9 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?

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…
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/🧵For months I’ve been grappling with what seemed like a real gap in conversations about #LongCOVID.

Here in @STATnews, I introduce you to 30 references & 3 #COVID survivors – Ray, Pam, and Carolyn – who taught me a lot. I hope you think so, too…
2/ "I feel like I'm getting the silent treatment & it's killing me," #LongCOVID pt Pamela Bishop confided in me about her months-long interactions as she tried to get answers about a strange array of symptoms that have plagued her since recovering from #Covid19.

Pam then & now…
3/ Up to1 in 3 COVID survivors report experiencing #longCovid symptoms 3 to 6 months later. Their stories give me an extreme case of déjà vu because this is playing out similarly to the problem of long-term survivorship after non-COVID critical illness.
Read 26 tweets
1/🧵 Dozens of #Ivermectin lawsuits now filed trying to FORCE doctors to give a worm & parasite drug to people infected with a VIRUS!

If you saw a movie with this tag-line, you’d say, “That is so stupid.” And yet…read on…
2/ There has been a mix of results in state courts. Some judges have refused to order hospitals to give ivermectin. Others HAVE ordered medical providers to give the medication, despite concerns it could be harmful.
3/ NY State Supreme Court Judge Porzio wrote: “This court will not require a doctor to be placed in a potentially unethical position committing medical malpractice by administering a medication for an unapproved, alleged off-label purpose.”
Read 9 tweets
1/🧵 Billing for #LongCOVID💰

It Matters!

What does it mean that docs can now bill using ICD-10 code U09.9 “Post COVID-19 condition, unspecified”effective October 1, 2021?

Let me explain a tad bit why this is so key.
2/ I fully believe in #LongCOVID, and patients must be validated as the experts of their own narrative. BUT, absence of a billing code sent a terrible message to clinicians & pts.

This legitimizes the #PublicHealth catastrophe & facilitates pts being HEARD & SEEN 👁.
3/ Docs “believe” better when they can charge for testing & get pts covered, too. This also allows databases to track & analyze epidemiology of #LongCOVID. That means research can be carried out to answer questions, improve care & prepare for future pandemics. Read an anecdote👇
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.
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

Adding baricitinib to steroids will save 1,000s of hospitalized #COVID pts. Our @LancetRespirMed COV-Barrier study is FREE.

I explain👇why it’s such a great #Pandemic discovery story: a new way to ⬇️ COVID19 deaths.
2/ Early in COVID, computers predicted “Berry” (for Bari-citinib), an FDA-approved medication for rheumatoid arthritis, could be repurposed to stop SARS-CoV-2 from killing us. Now we proved it! Why did the computers think it would work?
3/ Bari has antiviral mechanism but mainly we thought it would work by interfering with the intense inflammation the virus 🦠 causes, which is what leads to so much lung, heart, blood vessel, & brain damage (#delirium).
Read 15 tweets
1/🧵 The main question I wake up wanting to answer every day as a physician in the #COVID “I see you!” is this:

“How can I help people recover fully so that their dignity is upheld…so that the unique pricelessness…(read on)


2/ of every human being who comes into my care is such that they feel fully human, fully respected, and that they don’t think they lost part of themselves in the process of critical illness.”

Yet #LongCovid pts are telling me they’ve lost themselves.
3/ my colleague #delirium neuro @doctorShawniqua is haunted by this too. She’s trying to find out what exactly happens to the neurons & synapses in the brain of critical illness survivors so that we can manage people more safely during and after illness.
Read 4 tweets
1/🧵🎥 “Doc, TIME is BROKEN.” ⏰ #BRAINFOG in #COVID19 is something like this stuttering second-hand on a hospital room clock with a low battery. Imagine if your brain stuttered like this! This video was taken by an ICU survivor who told me how the clock contributed to #Delirium.
2/ Now our @CIBScenter ICU survivor @SGFesquire sees how the clock not only contributed to his delirium but symbolized his brokenness & need of healing (pic w perm). Brain Fog presents as delirium when 1st sick & as cognitive impairment (memory + mental slowness) in #LongCOVID.
Ongoing Brain Dysfunction = major suffering. Let’s be patient with #LongHaulers. They look normal & are silenced like #MECFS pts. Patients, seek help. We will help you “unbreak time.” We do this through cognitive rehabilitation tools. #recovery
Read 3 tweets
1/🧵🎥 MAJOR TIPS about #Liver Disease
Why do we ask pts to “hold up traffic”? When people get severe liver disease, “asterixis” is a finding on exam we often see.

What does it mean?
#MedTwitter #NurseTwitter #TipsforNewDocs #Addiction
2/ Asterixis indicates that toxins like ammonia have built up in the body because the scarred liver no longer filters them out. The brain cells no long function normally (#Delirium or Hepatic #Encephalopathy) & can no longer control muscle movements like posture!
3/ These same toxin cause vessels to dilate and develop problems with blood flow in the skin and lungs. A skin finding is called “spiders.” They look like a multi-legged spider, right? It’s a tip-off.
Read 9 tweets
1/ Imatinib for #COVID19: @TheLancet

This study of N=385 ICU pts tested a Tyrosine-Kinase Inhibitor vs. Plac for 9 days. It’s important because it did NOT decrease ventilator or oxygen needs BUT reduced death at 28 days. What does this mean?

2/ This study is technically “negative” because it didn’t hit the primary endpoint scientists “guessed” ahead of time as best choice to see if the drug works in #COVID: time to stopping ventilation & O2. Importantly, we sometimes GUESS WRONG! Next let’s look at other endpoints!
3/ This drug stops lung & blood vessel membranes from going haywire. It did not have safety problems & decreased DEATHS by ~50%, TIME on VENT by 5 days, length of ICU stay a WEEK, #delirium by 5%. These are huge improvements that I would want if I had #COVID. ( Fig 2, Tab 2/3)
Read 6 tweets
1/ 🎥🧵 How do we test someone for #delirium in #COVID19 or any ICU? When someone won’t engage it can be a huge red-flag for “quiet” delirium, which predicts 3X ⬆️ #DEATH by 6 mo & acquired #dementia. Watch this movie of me testing pt #1 for delirium.

#MedTwitter #NurseTwitter
2/ What does this mean? He starts out OK but then can’t follow my command to squeeze only on the letter A. Instead, he squeezes when I say the word “squeeze” & doesn’t relax his grip or vary it on different letters. This is inattention & a cardinal feature of #Delirium.
3/ 🎥 Contrast Pt 1 with this Pt 2 video of me doing the same test. This person had delirium on earlier days & is now improving. He gets 8/10 correct responses, which means he’s attentive and not delirious any more. This day he walked & talked for the 1st time!

#Recovery #nurse
Read 7 tweets
1/🧵An Epiphany: #delirium treated w touch & eye contact, day by day...his mom cried, “He won’t let us help him shake this damned disease.” Finally his mind cleared. “What matters to you? How can I help?” Slowly, surely, he asked, “Doc, can you help me stop drinking?”💔
2/ #GroundZero. What a privilege it is to witness someone enter a long-awaited epiphany that opens the door to so much recovery. Unfortunately, in my early years as a doc, I thought, “Well, this isn’t critical care, so I’ll move on & let someone else take over.”

#shame on me
3/ But what is a doctor for?

1. To reduce human suffering & heal people where they are.
2. Plus the Latin root is “docere,” teacher.

It’s a dual vocation: healer + teacher. Because of the “Law of the Gift,” I know that the more I give, the more I receive, so…

Read 7 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

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