Some #medtwitter #CritCareControversies musings on #COVID19 after my first week. (Thread)
1. It’s a new disease. Normal ICU routines don’t seem to work. When you think they are ready to wean from the vent, they are not. Desaturation is common and deep.
1. It’s a new disease. Normal ICU routines don’t seem to work. When you think they are ready to wean from the vent, they are not. Desaturation is common and deep.
2. They seem to like high PEEP as reported before. You can’t wean this fast as with a “normal” pneumonia. All this means light sedation doesn’t work and causes asynchrony. AKI is common and if caught early responds well to diuretics combo. Bloods are weirdly normal.
Still don’t understand what’s the best way to catch superinfection. CRP is up after day 2. We use PCT and it’s fine when sky high, but what about 2.0-3.0?? More data needed. Patients tolerate drying out without haemodynamic instability. Shock is not a prominent feature.
3. Communication w/ relatives is difficult as you can’t do F2F. Getting to grips with videoconferencing via secure channels (Thanks @oggsky and team!) especially important when views as not aligned.
4. Timing of procedures is important see first point that it’s not a “normal” icu pneumonia. Don’t rush any decision as change in position of pt can have dramatic effect on oxygenation. If you act, have your slickest available operator to perform whatever task needs performing.
5. Working in full PPE is tiresome. Regular breaks, hydration etc is key 🔑 support your staff as they learn with you and try to explain why you are not doing the “normal” ICU things we do. Don’t forget them though, your non-COVID19 pts need that approach!
7. The team response to this has been fantastic. But it’s not a sprint it’s a marathon. Pace yourself and your colleagues. Support each other. And have some rest switch off Twitter and the news, wash your hands, stay at home and flatten the curve so we can do our best.
Thanks for all individuals and businesses who has shown incredible kindness and support to us. It’s greatly appreciated. We will get through this and our care will be transformed. Over and out.
Further thoughts: when you admit the patient, your intubation team should place the invasive lines and NG tube after securing the airway. It makes a hectic 1-2 hours, but limits PPE waste, allows all drugs going centrally and you can keep RASS -3 as they are likely to need
High FiO2 and PEEP support for a while. You have to be patient and bring out the old and dirty tools from the ICU box. The more experienced consultants in your group are great to explain how things worked and didn’t work in the early 2000s. It’s painful to adjust the mindset!
It’s not your fault though, it’s a new thing: Until we find out what can effectively shorten the “very inflammed lung” period, we’ve only one option: rest the affected organ and try to avoid other complications. Maybe for two weeks. That is the hard part in this fast paced world.
