I've been dreading this, but I think we need to reconsider the issue of steroid in COVID-19. This is extremely complicated, especially for two reasons...(1/7) #COVID19foam
1st level of complication = patients vary a lot!
- Most require minimal care
- Many just need low flow oxygen
- Few develop cytokine storm and multiorgan failure
- Many are somewhere in-between
It may be *impossible* to render any blanket statement for all patients. (2/7)
2nd level of complication = disease goes thru phases in any patient
Rarely: later surge of adaptive immunity causes cytokine storm. Immunosuppression potentially good here?? (3/7)
currently best data on COVID-19 is a retrospective series of patients in Wuhan by Wu et al. this study has *lots* of limitations (e.g., single center, variety of different treatments used, most patients not intubated)
(study: bit.ly/33q6Uou)(4/7)
among patients with ARDS, methylprednisolone use correlated with improved survival. this is notable, because generally steroid is used for sicker patients (who will do *worse*). so is steroid actually causing benefit here?? (5/7)
it's impossible to know. this study suggests that it's reasonable to treat patients with ARDS plus systemic inflammation (e.g. markedly elevated CRP) with moderate doses of steroid (e.g. 0.5-1 mg/kg methylprednisolone).
(article: bit.ly/2Uf8tSa)(6/7)
steroid is a nonspecific immunosupressive. more targeted immunomodulators might be superior (e.g. tocilizumab). but for now, this is what we have. dexamethasone could be superior b/c it causes less fluid retention.
(more on steroid in IBCC here: bit.ly/3db51Re)(7/7)
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)