the remdesivir story continues to unfold in a genuinely weird way. before going further, let's not forget the "compassionate use" trial in NEJM which claimed success because everyone didn't die (which, in retrospect, is *definitely* hot garbage) (rant 1/4)
the NIH guidelines now recommend remdesivir for anyone with COVID-19 who is hospitalized with a saturation <94%. these recommendations are broader than the NIAID trial inclusion criteria- so even if the trial is very positive, this still seems like an over-reach (#rantorial 2/4)
the SCCM just released a statement promoting remdesivir, even though the NIAID trial remains unpublished. never mind about RCTs! the new approach to evaluating drugs is really good retrospective data sharing. cool, cool, cool. (#3/4)
(sccm.org/Blog/May-2020/…)
to show how well this approach works, the SCCM blog uses the Marini/Gattinoni model of "CARDS" as a success story. however, this H/L non-ARDS nonsense has largely been discredited & should be a *cautionary* tale of why we need to slow down and focus more on the evidence (4/4)
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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)