Discover and read the best of Twitter Threads about #icu

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Posting some reflections on the #ACTT & #RECOVERY trials related to #remdesivir & #dexamethasone for the treatment of #COVID19

Those results feel like definitive advances, but we need to realize their limitations and need for confirmation despite everyone's #pandemic fatigue

There are lot of skeptics in and outside of #Twitter on the results of both trials, strong emotions regarding big-pharma made medications, the way the #EUA was made, also about use of #steroids in the #ICU that has a quite rocky history among those who run those units.
And we need to acknowledge from the outset all sorts of basic, and not so basic, emotions that come in the doing clinical trials, exacerbated by academic cliques, national defense issues (and nationalisms) that can get exacerbated with the strains in health systems.
Read 21 tweets
Family members are integral to #ICU care but were unable to visit their loved ones during the pandemic - I'm excited to share a tweetorial on our recent #COVID19 study in @ATSBlueEditor

Our work builds on today's important @washingtonpost op-ed by @RanaAwdish and @WesElyMD…
Read 16 tweets
1/3-Back by request for new ICU residents!

💥 12 KEY TRIALS I teach on #ICU Rounds each week they must know!

Do you agree?
Any you would add?

1. ARDSNET @NEJM -PMID 10793162

2. LEUVEN Glucose 1 @NEJM-PMID 11794168

3. SAFE Trial @NEJM PMID: 15163774
#FOAMcc #medtwitter #MedEd
2/3 12 Key ICU trials I teach each week cont...

4. TRICC Trial @NEJM PMID: 9971864

5. SOAP Vasopressor trial @NEJM PMID: 20200382


7. Rivers EGDT @NEJM PMID 11794169

8. VAAST Trial @NEJM PMID 18305265

9. SMART Fluids @NEJM PMID 29485925
3/3 12 Key ICU trials I teach each week cont...


11. Schweickert Early Mobility @Lancet PMID19446324

12. ABC Trial @TheLancet PMID 18191684

What others would you add?
#FOAMcc #FOAMed #SCCMSoMe #medtwitter #MedEd #medstudenttwitter #ICU
Read 4 tweets
A #MedEd Thread for #pulm #criticalcare #applicants. How do you pick a program? What questions do you ask in a fellowship #interview? Here are some ways programs differ and tagged @IUPCCM experts to answer any questions you may have! #MedTwitter
#PAH: Does Pulm house pulmonary hypertension and manage vasodilator therapy? Or is this managed by a different department? Are there opportunities to learn this if so? @TimLahm @RFPMachado
#IP: Do you have experts performing advanced #bronchoscopy such as #navigational? Does Pulm place stents, valves? Is there #EBUS volume for general fellows to become proficient? How much of this is done by other departments such as Thoracics or ENT? @ChrisKniese
Read 13 tweets
Encephalopathy vs Delirium 🧠: 1/11

#COVID19 has profoundly amped this malady for millions...

ICU Doc asked: “Wes, what’s the difference between delirium & encephalopathy?” I chuckled, “Got an hour?” & distilled it down in 2 min.

#medtwitter #pulmcc #meded #tipsfornewdocs
Encephalopathy vs Delirium: 2/

20 years ago we started publishing our ICU Delirium papers. The biggy was in JAMA after being rejected by NEJM’s main Neurologist Reviewer because “we used the term delirium & not encephalopathy.”

So this confusion is STILL going on…
Encephalopathy vs Delirium: 3/

To help with this nomenclature problem, Arjen Slooter led us & we published this 2020 delphi study and paper endorsed by 10 med societies.

Intens Care Med:

#medtwitter #medstudenttwitter #pulmcc #tipsfornewdocs
Read 12 tweets
1/13 Our daughter is an #ICU #nurse on a #COVID19 unit at a suburban #Atlanta hospital. Since March on every shift she is facing disease and death on a massive constant scale, more in her young life than my wife and I—both physicians—ever had to cope with. We pray for her daily.
2/13 She is not particularly political, so when she called this week with a combination of fear, distress and anger about our #Georgia Governor’s position on masks we listened. And we had no answers. When she rhetorically asked what he was thinking we couldn’t say.
3/13 When she asked if he understood how many people are so ill from #coronavirus we had no idea. Then we realized our daughter is putting her life on the line daily like so many others and asked what would we do if God forbid we lost her as a result of her service.
Read 13 tweets
So remember when I wrote this thread in an effort to explain why, coming from a mechanism of action perspective, #hydroxychloroquine (#HCQ) for #COVID-19 should be administered with #zinc?
2/ Well, this NYU preprint explains how the team performed a retrospective observational study to compare #hospital outcomes among patients who received #HCQ + azithromycin + #zinc vs. HCQ + azithromycin alone for COVID-19:…
3/ They found that addition of #zinc sulfate to the #drug combo increased the frequency of patients being discharged home, and decreased the need for #ventilation, admission to the #ICU, and mortality or transfer to hospice for patients who were never admitted to the ICU.
Read 7 tweets
A #Tweetorial on Blood Gas Analysis (adapted from my WKRP in Cincinnati style method of teaching blood gases).
Blood gas interpretation is something that is initially very confusing, is usually poorly taught, comes up hourly in the #pedsICU and #ICU and will be on every exam for the rest of your life.
But it doesn't have to be that complicated and this method will get you through 99.99% of blood gas interpretation and serves as a good foundation to learn those exceptions. (So don't @ me!)
Read 27 tweets
Why #kidney function does not equal #GFR (and certainly not Cr), making it an elusive target in clinical practice & the latter a poor surrogate outcome, despite its robust correlation with prognosis. Caring for kidneys versus improving Cr/GFR. A thread below:
The kidneys in essence have 3 functions:
1. Glomerular function = Clearance
2. Tubular function = Homeostasis
3. Neurohumoral function

GFR mainly reflects 1. So why do we take GFR (or its estimate Cr) as a surrogate for renal function?
Look at GFR determinants (=N x snGFR).

In stable circumstances, GFR mainly reflects the number of functional nephrons.

Starting from 1 million per kidney at birth, one loses 5,000-10,000 per year with aging: age-related GFR decline <1 mL/min/1.73m²/y…
Read 9 tweets
#LongThread on #COVID19 #ICU Management in #Pakistan:
Spent last 15 days going thru the decaying orders of our healthcare system embattling Covid-19. A close relative was on bag-mask oxygen in emergency unit of a tertiary care. He developed SOB, fever on Eid day.
For days we were confused whether to treat it on Cytokine Release syndrome lines or not. Strong Neutrophilia was suggestive of sepsis as well. So some of my consultant friends cautioned against actemra.&we lost valuable time. Punj. gov criteria for actemra added to the confusion.
They had 3 lab parameters (ferritin, Crp, d-dimer) and all 3 of them had to be raised but they were never increased in unison; were rather increasing in tandem. Both these together meant we didn’t administer actemra until it was v late.
Read 23 tweets
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
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
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
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…
#Science #Galileo
Meet the ‘psychobiome’: the gut bacteria that may alter how you think, feel, and act…
#action #gut #bacteria #feel #think
How do children spread the coronavirus? The science still isn’t clear…
#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…
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%.…
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%..…
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

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)

Mortality in ICU
46/28% (!)

Ventilated in ICU

% of all death
>70yrs 86/86%

Care home deaths

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:…
#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
ICYMI back on Feb. 7, 2020, I published: "A Harvester of Sorrow – First Wave of the SARS 2.0 Novel Coronavirus" / #COVID19 #1918Pandemic #Pandemic #Coronavirus #SARS… Image
San Francisco had the 1918 flu under control. And then it lifted the restrictions #COVID19 #1918Pandemic #Pandemic #Coronavirus #SARS…
#COVID19 #1918Pandemic #Pandemic #Coronavirus #2ndWave no kidding, use summer as a time to prep just in case, no matter what anyone says, bc a virus is much smarter than any of you...
Read 318 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: @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

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