Thread by @CHESTCritCare

Covering pardon the interruption with @davidschulman moderating!!!!!

Power-packed speaker list covering a gamut of critical care topics at #CHEST2020

@SMHollenberg @ammo_uw @KristinBurkart3 and Dr. Bowton

And punches are already being thrown. D'oh!

Here are the competitors:
Dr. Bowton: The Real Deal Tarheel
@KristinBurkart3: The Beat of the Northeast
@SMHollenberg: The Heartless Cardiologist
@ammo_uw: Dr. "Who Can Ask for Anything" Morris

Here are the ground rules!

New rules this year!!

#CHEST2020

Role of glucocorticoids in CAP:
Dr. Bowton: No mortality benefit
@SMHollenberg: Loses points 4 trying to get points. "It's a toss-up"
@ammo_uw: "Depends": How do you define severe" They help for severe!
@KristinBurkart3: Do the "boys" never find indication? ... burn!

#CHEST2020

oooohh .. @KristinBurkart3 points out the metanalysis that showed benefit in severe pneumonia. @SMHollenberg counters: Have results ever been replicated!!!!

#CHEST2020

Topic: Antibiotics within 1 hour
@ammo_uw: Drips sarcasm: "just follow guidelines blindly". doesn't believe in linear benefit with time to administration. It's all retrospective. Recognizes the importance but key is "tailoring and stopping early"

#CHEST2020

.@KristinBurkart3: In septic shock: "Go big or go home". The risk of not starting on time is too high!
@SMHollenberg: "What should you not give them within the hour?" Agrees with @ammo_uw: Issue isn't the starting, it's the stopping!

#CHEST2020

@ammo_uw: Counters with the fact that not everything that looks like an infection, is not actually infection. So it's so important that if the suspicion of sepsis is high, use them.
Dr. Bowton: The data is for sepsis and shock. It's absolutely important to start ASAP #CHEST2020

This topic barely feels like a smackdown. They are ALL agreeing!!!

@KristinBurkart3: Doubles down saying for those with clinical infection who are severe, it is ABSOLUTELY important to get abx started ASAP!!!!

@davidschulman is getting bored w them getting along.

#CHEST2020

Next topic: Daily or continuous RRT?
@SMHollenberg: Continuously better tolerated and is easier in terms of resource strain on the nephrology service
@ammo_uw: No good RCT data. Feels folks overtly worried about hypotension. "Use what you have !"

#CHEST2020

Dr. Bowton: "Slow and longer intermittent would work same as CRRT". not about modality, more about aggressiveness of shifts.
@KristinBurkart3: Disagrees abt resource utilization. CRRT changes nursing ratio. Making ratio 1:1 to preserve HD personnel strains ICU

#CHEST2020

@SMHollenberg: "Our nurses are FANTASTIC"!

#CHEST2020

Topic: TTM at 36 or 33 centigrade?
@KristinBurkart3: All the benefit at 36, risks at 33: coagulopathy, shivering. "Go 36 for 24 hours"
Dr. Bowton: "No difference in shivering at 33 vs 36". Important to maintain < 26, point being avoid fevers!

#CHEST2020

.@ammo_uw: Last year's trial's normotemp group actually had high temps!
@SMHollenberg: Disagrees!!!! Some people do better at 33: Younger and those with profound coma. Actually they shiver lesser below 34!!!

And doesn't matter how quickly you get to 33.

#CHEST2020

Dr. B: "Cold better than hot"

@davidschulman: All choices are cold. That's not the point. 33 or 36.

@ammo_uw: Whr are U getting the fact: 33 is better?

@SMHollenberg: Some retrospective observational studies.

@KristinBurkart3: "You didn't just quote that in face of RCT data"

Next topic: MAP target of 80 mmHg in pts with chronic HTN and septic shock?

Dr. Bowton: I know the recent study data, "I'm not smart enough to base decisions on the limited data"

#Smackdown #CHEST2020

.@ammo_uw: "Data does not support higher MAP goals" mainly cuz we don't know who has chronic HTN coming in. Few data points on the chart doesn't mean a thing.

@KristinBurkart3: No mortality benefit in the study, in fact more afib, we know that has long term impact.

#CHEST2020

.@KristinBurkart3: I target 65 or above, not 80!

@SMHollenberg: Some patients may target 80, but not routinely. Raising targets intermittently to see if kidneys improve perfusion may be reasonable.

Dr. B: But we don't have a great timely marker to see improvement in renal fxn!

Topic: Should ultrasound be used to guide fluid management in sepsis.

@ammo_uw: "YES". Slence. Laughter, then continues. And use it augment your exam and overall assessment. "Use all tools in toolbox".
@SMHollenberg: It doesn't replace examination. You have to be good at it!

.@KristinBurkart3: Worry that inadequate knowledge and experience can lead to misuse. Knowing the limitations of the modality is key. More important concept is prevention of volume overload and #POCUS certainly helps there.

#CHEST2020

Dr. Bowton: "Just because you are fluid responsive does NOT mean you need more fluid"!!!!!!! BAM.

"Lack of responsiveness means stop the fluid".

So, question is, are you using #POCUS to measure the right thing!

#CHEST2020

.@ammo_uw: Pushes back on Dr. B's claim that SV changes with PLR is more reliable. She agrees that yes, #POCUS indices can be reliable, so important to learn how to do POCUS and do it regularly. Repeated measurements are key!

#CHEST2020

.@KristinBurkart3: "There are ZERO patient centered outcomes to support #POCUS use"

@ammo_uw: "There is no data for judging volume status from touching feet either!"

#CHEST2020

Topic: Should NIPPV be used for managing hypoxemic ALI?

@SMHollenberg: "For mild cases", watch patients closely, but don't keep watching forever

@KristinBurkart3: LUGN-SAFE invoked. Increased mortality when P/F < 150. So uses up to moderate Berlin but not higher!

#CHEST2020

Dr. Bowton: "Yu don't improve in 1 hour, need to intubate".

Dr. B and @KristinBurkart3: Look out for more data on helmet NIV from Drs. Kress and Hall's group.

@ammo_uw: "We don't have enough helmets!" Don't mess with elderly, immunosuppressed, and > mild P/F

#CHEST2020

.@davidschulman: Who uses NIV for mild ARDS??

@SMHollenberg: Will use NIV sometimes for mild ARDS. "But if you think patient needs to be intubated, then intubate them."

@ammo_uw: If it's pulm edema, NIV works.

@davidschulman: "Don't answer Qs I'm not asking"

#CHEST2020

Topic: Role of Vitamin C and thiamine for #sepsis
@KristinBurkart3: The Marik study's details were never replicated in any study. "There are risks, thiamine shortages have happened".

#CHEST2020

Dr. Bowton: "We don't need any more data, there are 4 good negative studies this year alone." WE ARE DONE!

@ammo_uw is trying to disagree for the sake of discussion. "There is a role for thiamine/Vit C I f patient is deficient". But she's not sold on it herself. #CHEST2020

.@SMHollenberg: "It's an unproven therapy". It shouldn't be used because giving things just because we can and that there may not be any harm is not a good logic for delivering interventions.

#CHEST2020

#COVID19 speed round:
Q: Empiric abx therpy

@ammo_uw: NO. Just no.
@KristinBurkart3: If they are in shock, they are getting abx from me
Dr. Bowton: Start abx. If intubated, get cultures to ensure guided therapy!

#CHEST2020.

#COVID19 speed round:
Q: Prophylactic vs full AC

@SMHollenberg: Double the dose of prophylactic dose
@KristinBurkart3: No data for "intermediate" dose, just use prophylactic dose. But low threshold for transitioning to higher doses. No studies have shown benefit.

#CHEST2020

.@KristinBurkart3: COVID19 patients bleed just as much as they clot. No data to suggest right now that empiric Rx is warranted.
Dr. Bowton: Quotes Sinai study. No indication of benefit from Rx doses. Also no indication of increased deaths from DVTs and PEs, so why?

#CHEST2020

#COVID19 speed round:
Q: Low or intermediate TV?
@KristinBurkart3: Please let's stick with what we know. None of this is new. Doing new things as a novelty is dangerous
@ammo_uw: Back Dr. Burkart. ARDSNet data is solid. Stick to LTVV in all comers with ARDS.

#CHEST2020

Dr. Bowton: No evidence of threshold effect with low tidal volume. So stay with LTVV. But disagrees with @KristinBurkart3: There is much more dead space. Certainly, the pathology is different but ARDS is still heterogeneous.

#CHEST2020

#COVID19 speed round:
Q: Current role of Swan Ganz outside pulmonary HTN?
Dr. Bowton: Post CABG and select patients with HF. But comfort is important so evidence in modern era does not support routine use.
@SMHollenberg: 2 scenarios: BiV failure, undiff status
#CHEST2020

.@KristinBurkart3: They get inserted and used once, then not used in the patient, stay in too long, increasingly dec exp in clinicians and bedside RNs, so absolutely should NOT be routine

#CHEST2020: It needs to be skill that's maintained!

SMACKDOWN IS OVER.

AND THE CHAMPION IS DR. KRISTIN BURKART!!!!!

DR. BOWTON DIGITALLY HANDS OVER HIS CHAMPIONSHIP BELT.

Well done @davidschulman

#CHEST2020