Thread by @PaulBerglMD

I know everyone is doing this, but here are my reflections after 2 wks in #ICU w/ #COVID19. Also includes lessons from our outstanding collaboration w/ #RapidResponseTeam

(1/12)

Much discussion on clinical phenotypes, but like any disease, #COVID19 is a spectrum. Here are 3 big phenotypes I saw

(2/2)

I’m more worried about running out of #intensivist, #RespiratoryTherapists, etc than running out of #ventilators. Given wide spectrum of disease, true expertise in mech ventilation needed. No 1-size-fits-all approach here

#COVID19 #VentilatorShortage

(3/12)

Nothing beats proning. I know many centers now doing this, reporting good results on #medtwitter.

Even post-pandemic, I’m going to try awake prone on HHHFNC for all pts w/ hypoxemic RF & acceptable WOB. Amazing strategy

(4/12)

Still not sure what to make of SpO2 vs SaO2 vs PaO2 discordances & not sure what to do clinically w/ it. Settled on checking SvO2 when in doubt to look at end-organ O2 delivery (but obviously major limitations there)

(5/12)

Also not sure what to do about #anticoagulation. Basically, I started empiric tx when discordance between minute ventilation & degree of hypoxemia in context of rising D-dimer

(6/12)

Proactive about diuresis from day 1, kept fluid balance net even. Challenges the idea of diuresing someone into AKI. AKI developing only in pts w/ high inflammatory state which is likely due to multiple mechanisms & never related to being in net fluid balance

(7/12)

Not sure what to do w/ CRP, ferritin, LDH, D-dimer, neutrophil-to-lymphocyte ratio, etc. These markers always correlate w/ clinical picture. Look at the patient, clinical trajectory, organ failures, etc

(8/12)

Very little #POCUS use (maybe 3 pts), and when I did, just to look at heart (RV esp), not lungs

Always #ccecho findings predicted by physical findings & context. Did not change mgmt.

Really doubt lung #POCUS has much role in ICU #COVID19 pts & would not #echofirst

(9/12)

Nurses & RTs have incredible resolve & still are most underappreciate resource (by general public) in #ICU care

Differences in outcomes for pts will ultimately be related to adequacy & quality of RN care, RT, #rapidresponse systems, not medications, # of vents, etc

(10/12)

Like any critical illness, encephalopathy & delirium are huge issues in older pts, likely to be a major contributor to why many older pts succumb to #COVID19

Difficult to manage #delirium when no visitors, pts kept prone, etc

(11/12)

Finally, emotional toll even higher than usual in ICU… Families, patients, everyone

I cannot imagine struggles of families in these times, probably very difficult to trust #healthcare team when you can't see it firsthand

Expect a big #ICU #burnout wave post #COVID19

(12/12)

Oh, and now that I get a break from #COVID19 and #ICU, I finally get all the fuss over #TigerKingNetflix