Thread by @PedsIntensiva

1/31 1st podcast & tweetorial for Pediatrica Intensiva, the art & science of pediatric intensive care.

Incredible real experience of battling 100s of #COVID19 cases with intensivists Giovanna Colombo & Lorenzo Grazioli from Bergamo, Italy

#ICU #pedsICU
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2/31 “The problem is seeing the outbreak in the other part of the world…is very different when you face it. Now the outbreak is here. We are the epicentre of the earthquake”

#COVID19 #ICU #PedsICU
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3/31 “Lombardy is one of the richest regions in Europe, & its healthcare is one of the best in Europe. If we are in this situation with #COVID19, you can imagine the rest of Europe”

#ICU #pedsICU
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4/31 “By the time we realised #COVID19 was there, it was already spreading in the community. In each country the outbreak curve is the same. There is no reason to think in your country it will be different”

#ICU #pedsICU
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5/31 “+++ undiagnosed #COVID19 cases. Told us we had to send tests to an outside lab & result would come in 6 hrs. But b/c of the numbers the tests came in 8 hrs, 12 hrs, 24 hrs, 48 hrs & 72 hours…This is the USA situation now”

#ICU #pedsICU
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6/31 “The hospital becomes part of the spreading of #COVID19. People & governments didn’t consider this risk & this caused spread here. The WHOLE hospital has to be prepared, otherwise the outbreak will be bigger & bigger & bigger”

#ICU #pedsICU
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7/31 “Isolate, don’t wait for test. The clinical presentation is VERY typical. All the CXRs are the same. All. You can copy & paste between patients. These kind of clinical parameters, before the swab is positive, can help you”

#COVID19 #ICU #PedsICU
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8/31 “You have to train your staff not to be infected. Do specific training. 1st week we lacked knowledge and had a lot of illness. After for 10 days we put someone at the door of ICU every shift to teach staff how to use PPE”

#COVID19 #ICU #pedsICU
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9/31 “You have to stock PPE because as soon as you get a #COVID19 outbreak, everyone wants PPE, and if you don’t have it, you don’t have it”

#ICU #pedsICU
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10/31 “Staff go home at the end of their shift. Our hospital policy is that exposure to #COVID19 with PPE is not exposure, unless symptomatic. Once you get symptoms, stay at home & get a swab in 3 days. If negative you return to work”

#ICU #PedsICU
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11/31 “Single isolation was only for our detection period. As soon as a #COVID19 test is positive, transfer the patient to cohort isolation. At some point your negative pressure rooms are full – and you cannot isolate anyone else”

#ICU #pedsICU
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12/31 “Wuhan’s experience was low rates of crit illness with #COVID19. Not here. ICU admission rate depends on age and comorbidities in your population, in Italy it is ¼ or 1/5. We only admit for invasive ventilation & 10 day admission typical”

#ICU
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13/31 “We are in a war zone here. In our 1000 bed hospital we closed up wards & programs, all outpatient clinics & built up cohort areas. Now, we have 400 #COVID19 patients. 56 intubated, 2 ECMO, 2 ECCOR, 12 on NIV, 80 CPAP on wards”

#ICU #pedsICU
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14/31 “We have surgeons & radiologists managing #COVID19 NIV patients on wards. We developed a score to ID patients who are young enough to save & sick enough for ICU. That tells our non intensivist colleagues who to discuss with us”

#ICU #pedsICU
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15/31 “You’ll get trouble trying to close clinics & elective surgery but it’s necessary. You can’t keep doing elective work as you are spreading infection. In the beginning we made this mistake. Reduce non #COVID19 work however you can”

#ICU #pedsICU
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16/31 “Peds wise just 2 admissions – both chronically ill & 2 newborns tested because of + mothers but well. Had to restrict the presence of parents –can just stay 1 hour per day. V difficult for parents, children & us as well”

#COVID19 #ICU #pedsICU
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17/31 “The reality is that pediatric staff, space & resources are having to be used to look after critically ill adults with #COVID19”

#ICU #pedsICU
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18/31 “When people die of #COVID19 we cannot admit the relatives – even to see the body”

#icu
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19/31 “This is a completely different scenario, we are really not prepared. Outbreak medicine is completely different. You have to think differently. You also have to think about community health. This was NOT my job 2weeks ago”

#COVID19 #ICU #pedsICU
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20/31 “Pts come to ICU after 2-3 days NIV. CXR is completely white. It’s interstitial disease & the problem is the inflammatory response. We are starting to use tocilizumab..seems to keep some NIV from needing intubation”

#COVID19 #ICU #pedsICU
apple.co/39QmpIV

21/31 “Young people have worse CXRs. If spont vent on NIV they cause self induced lung injury (SILI) because produce v high transpulmonary pressures. LOW (not high) CO2 is marker– if you see it, intubate ASAP or you’ll lose them”

#COVID19 #ICU #pedsICU
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22/31 “We intubate #COVID19 patients after 3-4 days NIV. They are good recruiters & respond to proning. After 3/4 days, CXR becomes black + lungs stiff + hypercapnia. Have to be brave & decrease the PEEP - but some of them de-recruit”

#ICU #pedsICU
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23/31 “Early intubation is a saving grace if NIV not going well in #COVID19. Patients seem to get better quicker if intubated. Use at least 3 days of NMBs. Once the CXR & gas improves don’t extubate too quickly or the lung will collapse”

#ICU #pedsICU
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24/31 “Currently, a 70 year old with #COVID19 & no comorbidities is too old to be admitted to ICU in our hospital. We have an age limit of 60 for ECMO. Unfortunately. If we were in peacetime, 1/2 these patients would be on #ECMO”

#ICU
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25/31 “We have an open space #COVID19 ICU – staff are inside for 8 hours in PPE. We had to shorten the shifts. We are losing weight! Your inner gloves are like your skin”

#ICU #pedsICU
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26/31 “By the time pts come to ICU, the virus is often clearing. It’s the inflammatory response we are dealing with. Antivirals maybe useful early but relatively limited role in ICU. We feel steroids are helpful in NIV patients”

#COVID19 #ICU #pedsICU
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27/31 “Glidescopes ideal for airway mx in #COVID19. W overwhelming numbers juith do what you can. We think intubation is safe for providers with FFP3 mask & visor, gown, gloves, hat, shoe covers. Chlorhexidine showers at shift end”

#ICU #PedsICU
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28/31 “We can’t afford to worry about aerosols from #COVID19 NIV pts. Use machines we have. 1 limb, 2 limb, anything. Staff in COVID iso area in PPE, protection at staff level. Ventilators use HME filters > active humidifiers”

#ICU #PedsICU
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29/31 “Lots of debate re. reducing aerosols or intubation risk in #COVID19 but wave comes so quickly that all these questions become academic. So what you should be mainly focussing on is reducing the size of the oncoming wave”

#ICU #pedsICU
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30/31 “Our staff are fantastic. They feel sorry when they test positive and have to stay at home while their colleagues are fighting. Strong leadership at hospital level makes a huge difference in the fight against #COVID19”

#ICU #pedsICU
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31/31 “You have to face the authorities & make them understand the problem of #COVID19 is big & that the economy is not as important at the moment. If you don’t have people after an outbreak….you don’t have an economy…”

#ICU #PedsICU
apple.co/39QmpIV

The link to the podcast is having some issues, try this or search for Pediatrica intensiva in iTunes podcasts.apple.com/au/podcast/ita…