Discover and read the best of Twitter Threads about #ICU

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THREAD
The latest @ICNARC report on ICU admissions was published last night, and on behalf of @ICS_updates and @COVID19actuary, please read this thread for an update
1/
There have been 321 new notifications of patients admitted to ICU with confirmed #COVID__19 . (9347 in total) This is largely static compared to last week, but still around 40% of 2 years’ worth of viral pneumonia admissions in ‘normal’ times
2/ Image
The distribution according to critical care network remains unchanged with London and the SE showing the greatest number of admissions. The new admissions this week appear to be concentrated in the London – South ODN
3/ Image
Read 15 tweets
Some more #COVIDDeepThoughts after post-ICU clinic this week. All of the patients we saw were #COVID19 survivors in their 40s-60s, previously relatively healthy, had been intubated in the #ICU, some for quite a while. 1st, the good news. All of them were home & many back at work.
We had done a lot of video visits beforehand, which made things go much more smoothly...because of the video visits, many patients had gotten medication adjustments and subspecialist referrals they needed before seeing us in person.
Observations: Everyone experienced delirium in the #ICU, even those w/o OVERT delirium...ppl w/ neg CAM-ICU, RASS 0, interacting seemingly appropriately. Important to ask about this...I took care of almost all of these pts myself in the ICU & wouldn’t have known if I didn’t ask.
Read 9 tweets
Daily Bookmarks to GAVNet 5/19/2020-2

Podcast: Galileo and the science deniers, and physicists probe the mysterious pion

nature.com/articles/d4158…
#Science #Galileo
Meet the ‘psychobiome’: the gut bacteria that may alter how you think, feel, and act

sciencemag.org/news/2020/05/m…
#action #gut #bacteria #feel #think
How do children spread the coronavirus? The science still isn’t clear

nature.com/articles/d4158…
#Children #spread #coronavirus
Read 8 tweets
Supposedly, #COVID19 patients who are put on a ventilator do terribly and are very likely to die. You’ve probably seen the headlines with 88% mortality.

A #tweetorial on the actual mortality of #COVID19 on the #ICU

independent.co.uk/news/world/ame…
Before we start, consider the “normal” mortality rate for a patient with acute respiratory failure on the ICU. Probably the best study to assess that is LUNG-SAFE. 50 countries. 4499 pt with ARF. 3022 #ARDS. ICU mortality = 34%.

jamanetwork.com/journals/jama/…
To the data! Remember that NY cohort in @JAMA_current; mortality was actually 24.5% at that point. The remaining patients were just not discharged! Just means that dying is quicker than surviving. So mortality is anywhere between 24.5% and 80%..
jamanetwork.com/journals/jama/…
Read 9 tweets
Attempt to understand differences 🇬🇧/🇩🇪 #Covid19 experience. Data comparability is challenging, and inevitably some of this may need further scrutiny. However, I do think there are a number of issues which warrant a discussion

1/16 (sorry)
Comparing some key indicators (🇬🇧/🇩🇪):

Cases +test
220/173k

Gender
M 56/48%
W 48/52%

# ICU beds used at peak
54%~3.3k (England)/<10% ~ 2.8k
Note: 🇩🇪 5x #ICU beds

Covid in 🇬🇧 hospital beds at peak 20k
🇩🇪 had 5k of Covid+ hospitalised at peak (not the same as beds)

2/16
Mortality in ICU
46/28% (!)

Ventilated in ICU
64/66%

% of all death
>70yrs 86/86%

Care home deaths
25/33%

3/16
Read 17 tweets
#Remdesivir begins distribution in the #USA today via #EUA.

I thought would write down some practical #tips based on my #qualitative anecdotal experience after personally treating close to 200 patients with #COVID19.

For quantitative results, wait for the papers¬—thread
“this juice works, doc!” When you hear similar expressions 1-2 days after starting #remdesivir multiple times, you start to wonder. Don't recall a similar proportion of patients smile after feeling so sick 1-2 days earlier with #COVID19. x/n? Wait for the papers.
Like #treatment for any severe infectious disease (meningitis, Gram-negative bacteremia, influenza pneumonia, etc), earlier is always better. #COVID19 is no different. #Remdesivir stops #SARS-CoV2 replication, but won’t heal the lung injury.
Read 13 tweets
I don’t like posting depressing posts but I think it’s time. When this all began, I would walk into the #COVID unit with the energy of a #hype man at a #hiphop show. I hate COVID19 but I love being an #ICU doctor & getting people better. Today I am mentally & physically exhausted
Other than my AM commute, I’ve seen daylight only once this week - today when I had a few minutes for a #coffee break. Today was also the first time I got home before 10 pm, but before I even had a chance to take my #decontamination shower...
I got called about yet another complex #COVID admission by my even more hard-working #PCCM fellows. The amount of face-to-face time required to take good care of these patients cannot be truly appreciated unless you’ve worked in an #ICU. The days are long & the work is relentless
Read 7 tweets
During #China’s fight against #Covid-19, the Chinese government adopted TWO FIRSTS approach: people first, the life and health first. China's national TV @CCTV 7 o’clock news on April 29 carried a few exceptional examples, miracles indeed:
1.The general cure rate in #Wuhan, the epicentre of the outbreak was 94%, while almost 90% of those in critical condition were able to return to normal life.
2. A 50-year-old Mr. Cheng suffered multiple organ failure and was the first patient to use #ECMO in his hospital. After 10-day #ICU care and was saved from near death He spent 80 days in the hospital and quarantine. He and doctors were tearful when he woke up.
Read 10 tweets
Missed #COVID19nCancer plenary in #AACR20 @AACR?
Here’s a thread to catch up on all the fascinating global research presented by:
@AACR @AACRPres #AntoniRibas #LiZhang @marinagarassino @barlesi #CarlosGomez #LouisVoigt #HongbingCai cc:@OncoAlert @COVID19nCCC @ASCO @ASH_hematology
#1: Chinese Experience by #LiZhang and #HongbingCai

More evidence of increased prevalence of #Cancer among #COVID19, ~2% similar to what we found in our #metanalysis @ASCO_pubs #JCOGO here: ascopubs.org/doi/10.1200/GO…
#LiZhang described 35.7% required mechanical ventilation and significant risk factors for severe outcomes on #multivariate analysis was recent #cancertreatment and #consolidation on CT
Read 12 tweets
1/Notes from the #COVID19 plateau:
2/In #Washington the total number of #COVID19 cases is down from the peak but not very far. In the hospital, it feels steady. Plenty of capacity for more if we need it. Thankfully, public health efforts and clinical surge planning prevented us from running out of beds.
3/I knew we were likely to have a long course, but I didn’t expect it to be this tiring. It feels like treading water. The surge wasn’t as big here, so the current levels don’t seem like a relief.
Read 10 tweets
The past few days have included a lot of thoughtful debate/discussion about #COVID19 and #ARDS, some snark (of which I too am guilty), and a hefty dose of HOW DARE YOU CHALLENGE A MASTER, YOUR RIGIDITY IS KILLING PEOPLE. I have a few things to say. Bear with me as I ramble a bit.
The idea that #EvidenceBasedMedicine does not allow for individualization for specific patients and changes in their clinical courses is a fallacy. Certain concepts that are known to save lives can & should be adhered to in a manner that is appropriate for the individual patient.
I thought this was obvious but that clearly is not everyone’s interpretation of #EBM. Also lung-protective ventilation does not = set it and forget it. Settings needed to maintain LPV will obviously change during a patient's course, something that experienced clinicians know.
Read 13 tweets
To provide some clarity about #COVID19 in #Sweden 🇸🇪, here's our insight into the public health measures, the current situation and considerations for the way forward: institut-fuer-globale-gesundheit.de/?p=2471 @BerlinIgg. Life in Sweden is not continuing as usual during the pandemic. 1/18
Sweden’s strategy may be different from other countries, as it aims not only at reducing #COVID19 transmission but also at reaching other important health goals. The strategy combines regulations and advice with a strong emphasis on individuals’ responsibility for action. 🌍 2/18
Sweden is implementing #COVID19-related interventions with the same aspirations as other countries: reduce transmission and #FlattenTheCurve. 3/18
Read 18 tweets
Some #COVIDDeepThoughts / reflections on clinical care in the #COVID #ICU now that I’ve had a chance to slow down a bit. It seems like a lot of folks are reaching for explanations for why #COVID19-related respiratory failure is something different & exotic & somehow not #ARDS.
As a result, a lot of pretty out there treatments with significant risks and downsides associated with them are being suggested by physicians, many of whom did not regularly care for #ARDS patients pre-#COVID19. These are being hyped up in the press & families are asking for them
I get it, it’s a lot less exciting to say “the patient recovered from #COVID19 w/ meticulous supportive #ARDS care” than it is to say “I did this weird new thing or gave this specific drug & the patient miraculously got better.” But #fundamentals >>> hype & unproven therapies
Read 8 tweets
1/ Big thanks all of you on @Twitter for the interest in my thread regarding current literature on #microthrombi and #COVID19!

It’s late, so of course, more thinking and more questions about #SARSCoV2

THREAD

@ASH_hematology @EricTopol @tmprowell @kari_jerge #medtwitter
2/ Conclusion 1: I am convinced the primary driver of #SARSCOV2 infection is in asymptomatic individuals #medtwitter #nursetwitter #epitwitter

SARS-CoV-2 titers in wastewater are higher than expected from clinically confirmed cases
medrxiv.org/content/10.110…
3/ Conclusion 2: #SARSCOV2 does not discriminate. It literally infects EVERYONE.

Newborns, kids, young adults, elderly you name it…it’s infected it. Everyone has #Ace2 receptors.

Children ARE getting it (see #China data and reports of acro-ischemia and
petechiae)
Read 20 tweets
How does the #pandemic end & how do we prevent a deadly resurgence of #Covid_19 later in the year? Release young people back into society first, a new paper says...
Bad situations occur if there is too little #socialdistancing (upper panel) or too much, causing a second wave of deaths (lower, an extreme case). Total mortality = TM; Green curves = #infections; blue = #ICU cases...
Here’s what happens if you release under 39 year-olds first. Here, either 2/3rds are released (assuming 1/3 live with older relatives; upper panels) or ALL of them are let out (lower panels). Total deaths drop from 1.5M to 900K to 390K...
Read 7 tweets
High blood pressure, heart problems or diabetes, or chronic respiratory conditions gives a greater risk of serious illness from #COVID19 and #influenza.
Should we ban fast food and obesitas out of our lifestyle?🤔

theguardian.com/world/2020/mar…
In Chicago, 70% of #COVIDー19 Deaths Are Black
Underlying diseases like high bloodpressure, obesitas and diabetes

wbez.org/stories/in-chi…
The Epidemic of #obesity and #diabetes
Both obesity and diabetes mellitus are important independent risk factors for the development of cardiovascular disease.
#COVID19Pandemic

ncbi.nlm.nih.gov/pmc/articles/P…
Read 11 tweets
After spending the last four weeks working in an #ICU here in #Seattle, a final set of #COVID19 clinical and general thoughts:

#COVID4MDs #seattlecovid19 #medtwitter (1/10)
Last week’s diagnoses are this week’s admissions. We’ve started to see people admitted to the ICU with known #COVID19 diagnoses but whose condition has worsened. Sometimes, as others have observed, the worsening is quick—in a matter of hours. (2/10)
People admitted to the #ICU with #COVID19 stay for a long time. We have had people on ventilators for well over a week. They have bad ARDS but do seem to respond to LPV, NM blockade, and being proned. Still, most have yet to come off the ventilator. (3/10)
Read 10 tweets
I know everyone is doing this, but here are my reflections after 2 wks in #ICU w/ #COVID19. Also includes lessons from our outstanding collaboration w/ #RapidResponseTeam

(1/12)
Much discussion on clinical phenotypes, but like any disease, #COVID19 is a spectrum. Here are 3 big phenotypes I saw

(2/2)
I’m more worried about running out of #intensivist, #RespiratoryTherapists, etc than running out of #ventilators. Given wide spectrum of disease, true expertise in mech ventilation needed. No 1-size-fits-all approach here

#COVID19 #VentilatorShortage

(3/12)
Read 13 tweets
Starting a series on clinical Pearls I am gathering in #COVID19 patients based on experiences of many experts

Will add as we go along

Feel free to add your own observations/experiences

#covidclinicalpearls /1
Anosmia is likely the most specific #COVID19 related symptom
30% of patients have anosmia as their 1st symptom
#covidclinicalpearls /2
Around 90% of patients have fever.
50% maybe afebrile at the time of presentation
Fever tends to be very resistant to routine measures in hospitalized patients
There is no consensus that NSAIDs are to be avoided in #COVID2019 patients

#covidclinicalpearls /3
Read 66 tweets
(1/) I want to bounce around a disease model for #COVID19. This is hypothesis, some parts are hand-wavy, but I'd like to think a lot is also based on evidence. I'll try to clearly distinguish knowns from assumptions as we go...

#COVID2019 #SARSCoV2 #medtwitter #FOAMcc #FOAMed
(2/)First, whatever #COVID19 is, it doesn't sound like #ARDS. Physiology doesn't line up
1-Easy to vent, but hard to oxygenate. Normal lung compliance
2-Deteriorate rapidly
3-Responds to proning, PEEP, & prolonging I:E
4-Tendency to suddenly de-recruit

atsjournals.org/doi/abs/10.116…
Read 23 tweets
THREAD👇

Hey #ICU #CriticalCare #QoL folks

Want to take a quick break from COVID19 research?

Here's a tour of the new @AnnalsATS I&P piece by me, Michael Hurley, @IanOppenheim, @DrMeganHoseyPhD, @AnnEkedahl

bit.ly/3dPdny1
Recent systematic reviews of services & interventions to improve Quality of Life (QoL) for ICU survivors have been pretty dismal. So we decided to go back to the drawing board and review some fundamentals. #ICU
Definition 1:
@WHO defines QoL as:
“an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns.”
Read 24 tweets
Official guidance from #ESPEN about nutritional management of #COVIDー19 clinicalnutritionjournal.com/article/S0261-…
A useful summary of nutrition/malnutrition, immune function and critical care.
But in reality, #ICU is different... FWIW a personal interpretation of limited experience thus far..
Assume every patient with #COVID19 is at high risk of malnutrition, whether co-morbidities exist, or not. Difficulties in breathing (DIB) compromises oral intake whether or not non-invasive ventilation (NIV) is used. Plus patients are being admitted well along the disease pathway
Use a feed protocol where possible. Most #ICU have one. Ours follows a 4-hourly escalation in NG feed rate tempered for patients on high level vasopressors. Protocols inform unfamiliar staff with normal ICU practices when ventilated numbers escalate.
Read 15 tweets
🚨📢 #Tweetorial on #ICU nutritional management in #COVID19 – disclaimer this is from my own insights having worked as an ICU #dietitian & working as a #juniordoctor #Hammersmith ICU resources will be tagged at the end - WARNING it’s long - so grab a ☕️ 1/13
Calculating requirements (Energy)
▪️If BMI>25 therefore opt for AIBW/IBW
▪️Many with single organ failure, ventilated & febrile +
▪️Equations to help – PENN STATE & Mifflin St Jeor – factors temp/vent settings OR if in doubt or time limits ASPEN BMI>30 11-14kcal/kg/ABW/day 2/13
Calculating requirements (Energy)
▪️We anticipate most pt’s will receive only 70% of feed due to variety of issues (proning, aspiration risk/placement delays)
▪️Don’t despair but prioritise tolerance and build up feed and ⬆️ protein provision 3/13
Read 13 tweets
My friend whose father is in the #ICU with #COVID19 has a request:

***#Hospital ICUs Need Phone Chargers****

Please consider taking 3 minutes to send a charger to your local hospital.

****Please Share This****
[1 of 7]
While we hope the big tech companies will step up and donate phone chargers to hospitals everywhere, please help me get the word out and take action now.

If we each go online, buy a phone charger or two, and have it shipped to your local hospital...
[2 of 7]
(if that hospital is set up to receive Covid patients), you will be helping those quarantined patients to stay connected to their families as they fight for their lives.

!!!No one even knows this is a problem yet!!!

Only those suffering and dying alone...
[3 of 7]
Read 7 tweets

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