Thread by @iBookCC

Going thru the Surviving Sepsis Campaign guidelines on COVID. There's some good stuff here, if you can skip thru the usual SSC boiler-plate nonsense (lactate as a perfusion endpoint 🤣).
(guidelines: bit.ly/2QvTm5x)
#COVID19foam

Air quality:
- SSC rec's negative pressure rooms for aerosol-generating procedures. Sure, but we are rapidly running out of them.
- When negative pressure isn't available, HEPA filters should be used whenever possible (they asked: how many? GIVE ME ALL THE HEPA FILTERS).

Masks
- SSC rec's surgical masks for non-vented patients who aren't undergoing aerosol-generating procedures
- Try to conserve N95s for when they are absolutely needed
- Sensible advice if N95 supply limited (risk of burning through the supply of N95s on COVID rule-outs)

Diagnostics for intubated pts:
- Tracheal aspirate preferred (not bronch!)
- Nasopharyngeal swabs can be false-negative.
- Co-infection occurs, so finding another virus doesn't r/o COVID.

there's a bunch of filler material on hemodynamic support, which is extremely weak because:
- incidence of shock is variable, seems *low* overall
- zero evidence specific to COVID
- tendency to lump cardiogenic & distributive shock together

I'm going to skip this nonsense....

SCCM recommends targeting an oxygen saturation no higher than 96% (i.e. target saturation 93-96%). all theoretical considerations aside, this seems like very practical guidance (given that some hospitals are at risk of running out of oxygen 😬).

SCCM rec's using HFNC as a front-line modality for patients failing low-flow nasal cannula (*consistent* with ANZICS guidelines as well). nice discussion of the fact that HFNC is probably *safer* than intubation from a virus-transmission standpoint. 👏

Noninvasive ventilation
🌬️Can be used if HFNC unavailable or other pulmonary issue (eg COPD or CHF)
🌬️Lack of distinction between BiPAP vs. CPAP renders this murky
🌬️Helmet sounds pretty sweet (but not widely available in the US). #IWantTheHelmet

next there's a bunch of boilerplate stuff on ARDS. this is generic (no data on COVID) so I'm going to skip this...

although it's notable that SSC suggests using traditional recruitment maneuvers for refractory hypoxemia (e.g. 40 cm for 40 sec)... but doesn't mention APRV at all?? this is strange, let's just keep going...

VV ECMO is suggested for refractory hypoxemia. the problem will be logistic. can we rapidly clone @ECMOprincess and @FOAMecmo ??

SSC recommends low-dose steroids for intubated COVID patients with ARDS. nice literature review. I'm agreeing with the SSC a lot today - is this a sign of the coming of the apocalypse?

SSC recommends empiric antimicrobial therapy for possible bacterial co-infection, which makes sense. they dodged the issue of exactly how to peel off these antibiotics (cough, cough, cough, procalcitonin 🤐)

SSC recommends acetaminophen for fever control, with a goal of improving comfort. interesting. I've been using scheduled acetaminophen in these folks with a goal of providing analgesia... so, same difference? 🤷‍♂️

SSC recommends against using lopinavir/ritonavir. yep.
that drug is totally, like, last week!
(blog on NEJM trial showing it doesn't work: bit.ly/398im9N).

SSC doesn't make any recommendation on remdesivir, which makes sense as no clinical evidence exists.

SSC also doesn't make any recommendation regarding (hydroxy)chloroquine. however, the guidelines were released before the recent study from Marseilles (more on hydroxychloroquine here bit.ly/3bpXXP5)

SSC also makes no recommendations regarding tocilizumab. side-effects exist, but the risk/benefit ratio could be better for someone who is dying versus someone with rheumatoid arthritis? time will tell.