Discover and read the best of Twitter Threads about #criticalcare

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Another #CriticalCare #Tweetorial!

🫀Left Ventricular Assist Device for the non-cardiologist🫀

Join me on a journey through LVADs with some #FOAMcc highlights useful for #CritCare #EmergencyMedicine #HospitalMedicine #Meded

@CardioNerds @emoryheart
Goals for this #Tweetorial
1-Review the basics of what an LVAD is and does
2-Discuss indications for an LVAD
3-Review some common complications of the device itself
4-Review systemic complications of an LVAD

Lets start with some basics of the LVAD. Historically the two most commonly encountered are the Heartmate 3 and the Heartware.

We will focus on the Heartmate 3 (Shown below)

Read 23 tweets
Calling all #POCUS fans, and #criticalcare 💓 afficionados! Asking if we have the right tools to identify RV dysfunction (RVD) in ICU?? We took an unbiased view (paper link at end of a long thread 🧵)....
The RV is not regular and so dysfunction can sometimes be found in one measure but not another - the crooked RV demands more than one guard to be caught playing up! 🇺🇲🇨🇦🇪🇺 consensus cardiology guidelines suggest looking at FAC and TAPSE to define RV systolic dysfunction:
In ICU tho pts are dissimilar to those cardiology sees. Acute pathology with RVD has been variably defined. Acute PE is a useful start; though systolic dysfncn is a prognostic TTE marker RV dilatation and septal behaviour is better recognised. Notably⬆️Troponin --> ⬆️risk too
Read 18 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
Thank you to everyone who responded to our call below.

All signposts to resources/networks/committees will appear in the following Wiley texts (if proposals accepted), see thread 🧵👇🏻

#AdvancedPractice #ACP #ACCP #SCP #CNS #FCP #ANP @HonoraryGeordi_
📕#ACP at a glance - approved, due in print Autumn/Winter 2022
📙#AdvancedPractice Framework (APF) for UK practice - approved, due in print Autumn/Winter 2022
📘 APF for Acute, Emergency & Crit Care - proposal under peer review

#CriticalCare #emergencymedicine #ACCP #ECACP
📗 APF for #Paediatric & Child Health - proposal in development
📙 APF for MH, LD & Autism - initial expressions of interest (EOIs)
📕 APF for #PrimaryCare - initial EOIs
📘 APF for #Frailty , Rehabilitation & community-based care - (initial EOIs!)

#AdvancedPractice #ACP #AP
Read 4 tweets
Why we #pocus: unexpected complications and daily changes. A thread.

70 year old male presented with hypoxic respiratory failure. Initially diagnosed with bilateral pneumonia and started on zosyn. Very hypoxic requiring 15L. The following morning #pocus revealed:
Large bilateral pleural effusion a with compression atelectasis. Clinically was never pneumonia. Was upgraded to ICU and intubated. R sided thoracentesis drained 1.8L of fluid and was stepped out of ICU
The following morning lung #pocus exam done. Left lung: lung sliding with diffuse lung rockets consistent with pulmonary edema
Read 11 tweets
28-DEC-2021 UPDATE

In this 🧵, latest #COVID19 hospitalization data for children 0-17 yrs and adolescents 18-19 yrs, through 27-DEC-2021.
#epitwitter #PedsICU #tweetiatrician #criticalcare #OmicronVariant #longcovidkids

H/T @JasonSalemi…
28-DEC-2021 UPDATE

During the 7 days ending 27-Dec, #COVID19 admissions (confirmed diagnosis) totaled 508 adolescents 18-19 years old and 2,305 children 0-17 years old.…
28-DEC-2021 UPDATE

Hospital inpatient census of children 0-17 years old with confirmed #COVID19 was 1,146 on Christmas Eve.…
Read 21 tweets
Time for a #CriticalCare #Tweetorial!

‼️Basics of CRRT for the non-nephrologist‼️

Exiting my typical #Neurology wheelhouse as I tackle some #FOAMcc topics for my own learning. Please join in on teaching and address any mistakes!

CRRT- What does it stand for?!

Continuous- Runs around the clock (sort of)
Renal- The beans!
Replacement- More of a rinse than a true replacement
Therapy- It helps!

@criticalbeansmd @EmoryNeuroCrit @caseyalbin @KrafteKraft4 @mallyaa @VijayanMD
Why do we use CRRT instead of HD?

Patient’s with hemodynamic instability (ie blood pressure is so low they can’t tolerate HD)

Conditions where you need to avoid large fluid shifts (like cerebral edema)

Read 21 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/🧵🎥 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.”

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/🧵 I lost a women into the clutches of death recently who reminded me of 2 other amazing women. Let me tell you about them…

My recent pt & Sarah both had hopes of raising their children, but it wasn’t to be so… (these stories are shared w perm)
2/ Sarah was a young woman who had just had a baby and was suffering from a disease of the 💔that happens after pregnancy. Here is my first paragraph about her from #EveryDeepDrawnBreath
“In my third year of medical school, my first patient was Sarah Bollich. Sarah had grown up in a clapboard shotgun house on Desire Street in the Ninth Ward in East New Orleans. She was twenty-three years old with a one-week-old baby…
Read 16 tweets
1/🧵🎥 Leading #COVID19 ICU Doctor @DavidJanz5 in New Orleans, the epicenter of U.S. #DeltaVariant surge, testified before US Senate Committee on Health, Education & Labor. Here is what he said: “Studies of #FrontLine workers caring for COVID-19 patients have shown…👇
2/ that the risk for the development of #mentalhealth problems (#PTSD #Depression) are like 9/11 Terrorist Attacks & Hurricane Katrina. Recent research shows that over 1 in 3 healthcare workers are experiencing anxiety, depression & post-traumatic stress disorder.
3/ Symptoms of #burnout are experienced by over half of critical care physicians. This is the state of the workforce asked to return to the #COVID19 #frontlines for a second, third, and now fourth wave.
Read 9 tweets
1/ 🧵 What is “Brain Fog” in #COVID19: discussion, papers & pts
 Brain Fog is a non-medical term but it works since it’s what pts describe. Whether in a ward, ICU on a vent, or months later as a #LongHauler w #LongCOVID, they are “in a fog.”

2/ Medically this is #Delirium acutely and #Dementia chronically + various forms of neuropsychological impairment coupled with #depression and #PTSD.
Our paper:
3/ Scientifically, it’s millions of neurons sick, dying or dead. This is depersonalizing & devastating. Fig A shows MRI 3 mos after ICU in pt w/out delirium vs B shows ICU pt w #Delirium. Duration of delirium predicted loss of 🧠 tissue.

Our MRI study -
Read 13 tweets
1/ 🧵A picture is worth 1,000 words 👁 #COVID19:

This 🎥 shows a clear example of what can happen to a person’s body w #COVID. His wife asked me to show it on twitter & urges everyone to get #vaccinate

(w/ consent of pt & wife)

#MedTwitter #NurseTwitter #CriticalCare
2/ You’ll notice his eyes are swollen shut. (Written perm to show). This is not fluid. It’s AIR from inside his chest leaking out his lungs 🫁 through muscles & skin to his neck & into his face. He is AWAKE & communicating but had ICU #delirium earlier.

#MedStudentTwitter #Nurse
3/ Look at his chest CT. See the “L” lungs w #Covid pneumonia/#ARDS & also AIR leaking out under his skin. Now go back to 1st tweet & watch 🎥 again. This is called “barotrauma” & happens when the 🫁s get too stiff and pop. Difficult situation. We’re hoping he can heal!

Read 5 tweets
There's a FANTASTIC ethnography of ECMO in press @AnnalsofSurgery with 380 hours of observations and 47 interviews with families and clinicians of 20 #ecmo patients. There are A LOT of parallels to mechanical ventilation in the #ICU.

@ATSEthicsCOI #CriticalCare #MedTwitter
Phase I of ECMO: Was there ever really a choice? When the options are "miracle" vs "lay there and die" why are we even asking? (besides being legally required)
Phase II: The clinical team believes they own the patient's body. They escalate care until they feel they've hit the "care ceiling" and there's nothing left to do.
Read 7 tweets
Your patient that is “over breathing” the vent may still be dead by brain criteria.

A #tweetorial #medtweetorial for providers in #criticalcare #EM #neuro #neurocriticalcare. @MedTweetorials
First and foremost, let’s be clear that to be dead by brain criteria, the patient must have cessation of ALL brain function *INCLUDING absence of respiratory drive.*

Thinking "But... I thought you just said...."?
The contradiction here lies in that ventilators are sometimes too sensitive.
Read 13 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.”
#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/ What causes #AKI with extracorporeal membrane oxygenation (ECMO)?

🗣️🗣️Let’s explore this 🔥topic from #NephMadness 2021

🧵#tweetorial #CriticalCare #NephTwitter @NSMCinternship @ASPNeph

Poll: How common is AKI in patients receiving ECMO?
2/ Basics first:
⚡️ECMO: temporary mechanical assistance device that provides prolonged cardiopulmonary support

⚡️Venovenous (VV) ECMO→ full respiratory support
⚡️Venoarterial (VA) ECMO→ both respiratory and hemodynamic support…
3/ Why are we talking about #ECMO?🤔🤔

⭐️Data from @ELSOOrg (Extracorporeal Life Support Organization): ⬆️📈⬆️in number of centers performing ECMO, and the number of runs (courses) per year
Read 18 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
Dr. Cook begins her #CCC50 Lifetime Achievement Award talk with reflection on her own 1st presentation ever as an #ICU fellow- at an @SCCM Congress! She was struck by the interprofessional group of attendees.(Thread)

#NationalWomenPhysiciansDay #WomenInMedicine #clinicalresearch
Her first lesson learned to impart to us.


An early senior researcher said to her early in career:
"I just don't think research is in your future"

Imagine what #CriticalCare world would have lost if she had listened.

#CCC50 #pulmcc #PedsICU
Dr. Cook: Sometimes dialogue is more important than consensus. You have the TRUST YOUR GUT. #CCC50

You're not growing until you're changing. Defining moments for bravery may come along when you least expect them. Be brave. #WomensPhysicianDay #PedsICU #pulmcc #ICU
Read 14 tweets
Only order tests when it will affect clinical decisions! The routine ordering of tests increases health care costs, doesn’t benefit patients and may in fact harm them.

#FOAMed #MedEd #medtwitter #zentensivist
Transfusing RBCs at a threshold of 7 g/dL is associated with similar or improved survival, fewer complications and reduced costs compared to higher transfusion triggers.

#FOAMed #MedEd #medtwitter #zentensivist
Read 6 tweets
Since #COVID hit, we're hearing a lot about critical illness #myopathy (CIM). Follow this tweetorial that will cover the basic aspect of CIM. Photos below are from a patient with COVID-related CIM.
CIM is a syndrome rather than a distinct entity. It refers to patients who develop a myopathy while being critically ill. The classic characteristic histologic finding is that of "myosinolysis" or loss of myosin.
As the muscle fiber type is determined by the myosin heavy chains, loss of myosin results in "unclassifiable" fibers. Biopsy photos show ATPase reaction at pH9.4 (left), type 2 in dark brown (type 1 light brown), and pH 4.3 (right) with type 1 in dark brown (type 2 pink).
Read 9 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.
Read 10 tweets

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