Thread by @iBookCC

#1/12 Going thru the fresh ANZICS guidelines, to make sure that important points are included in the IBCC. will tweet out some pearls from them...
(full guidelines: bit.ly/2x68dwG)
(IBCC chapter: emcrit.org/ibcc/covid19/)

#2/12 ANZICS recommends airborne precautions for known COVID patients in ICU. This makes sense, especially given today's NEJM article about the plausibility of airborne transmission. In the United States, I worry that N95 masks will be exhausted soon.

https://twitter.com/iBookCC/status/1240020983169331200?s=20

#3/12 ANZICS recommends minimization of stethoscope use. Yep, sticking fomites into my ear isn't an attractive concept. and how often do we really change our plan based on disposable stethescopes? #POCUS #CoarseBreathSounds

#4/12 ANZICS says to consider a separation of COVID-19 teams from "clean teams." This could help reduce virus transmission to critically ill patients who don't have COVID (and who are at incredibly high risk if they were to become infected).

#5/12 Staff at high risk should not enter COVID-19 isolation areas (including pregnancy, significant chronic respiratory illness, or immunocompromise). Hard to know exactly where to draw the line, but protecting at-risk staff is of paramount importance!

#6/12 Plan carefully for how to run codes and who should be there. A poorly orchestrated code with tons of people could burn through lots of PPE, while unnecessarily exposing excess attendees.

#7/12 High-flow nasal cannula *is* recommended with airborne precautions (risk of transmission is low). Noninvasive ventilation isn't routinely recommended. This is consistent with current IBCC approaches (although I do remain intrigued by the possibility of using *CPAP*)

#8/12 Mechanical ventilation: COVID patients love their positive pressure. Either high PEEP levels or APRV may be used. Try to avoid breaking/changing the circuit if you don't have to (and keep connections between tubes tight so they don't pop off!).

#9/12 Fluid management
- Restrictive fluid strategy recommended.
- Avoid "maintenance" intravenous fluids.
- Avoid fluid bolus for hypotension.
- No mention of any 30 cc/kg fluid nonsense.

#10/12 Extubation
- HFNC and/or NIV (with good fit & separate inspiratory/expiratory limbs) *can* be considered as post-extubation support... along with strict airborne precautions.
(This seems wise given some recent concerns about high re-intubation rates in these patients).

#11/12 Bronchoscopy is not recommended!
- Bronch *unnecessary* for diagnosis, dangerous, should be avoided.
- Tracheal aspirates sufficient.
(Some recommend bronchoscopy for diagnosis of COVID-19, but seriously - this is cray cray)

#12/12 Specific therapy
- None proven
- Routine steroid for all comers w/ COVID not recommended (could consider in pts with additional indication).