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Nick Mark MD Profile picture
@nickmmark
Jan 21, 2022 • 9 tweets • 6 min read • Read on X
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The ivermectin crazies are now recommending hydroxychloroquine too.

Their “protocol” includes a dangerously high dose of diuretics & recommends high dose steroids in people not on supplemental O2.

This has crossed the line from (mostly) harmless nonsense to actual harm.
Supporting Evidence:

A 2021 Cochrane meta-analysis (the 🥇standard) concluded that HCQ “has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo…”

cochranelibrary.com/content?templa…
A more recent meta-analysis in @NatureComms that included unpublished studies went further, concluding “that treatment with hydroxychloroquine is associated with increased mortality in COVID-19 patients”

nature.com/articles/s4146…
Regarding steroids:
The UK RECOVERY trial found that among hospitalized inpatients w/ COVID, dexamethasone 6 mg PO/IV reduced mortality

They also found a HARM signal among people NOT on supplemental Oxygen. That’s why we ONLY use Dex in inpatients on O2!
nejm.org/doi/full/10.10…
A Cochrane MA concluded “there is no evidence for [steroids in] asymptomatic or mild disease (non-hospitalised participants)”
pubmed.ncbi.nlm.nih.gov/34396514/
Another MA examined steroids in people not on O2 & found INCREASED duration of fever, DELAYED time to viral clearance, & LONGER hospital length of stay, concluding “steroids in non-O2 requiring COVID-19 patients can be more detrimental than beneficial.”
pubmed.ncbi.nlm.nih.gov/34347106/
The spironolactone label shows a big potential harm: hyperkalemia

The recommended starting dose is lower & checking serum K+ levels is advised.

Caution is advised in people taking ACEi, NSAIDS, & other meds.

The “protocol” doesn’t mention any of this!
accessdata.fda.gov/drugsatfda_doc…
Bottom line: several aspects of FLCCC’s new I-MASK+ protocol are potentially very dangerous.

This is way worse than just presenting ivermectin as a “vaccine alternative.”

Based on the evidence & clinical practice guidelines, these recommendations are likely to cause real harm.
To put it another way:
If a person died while being treated with these meds (especially if they died from an arrhythmia), I would list the “I-MASK” protocol as a contributing factor.

It is truly malpractice to encourage this. Medical boards take notice. @ABIMFoundation @TheFSMB

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More from @nickmmark

Nick Mark MD Profile picture
Oct 13
#HurricaneHelene damaged the factory responsible for manufacturing over 60% of all IV fluids used in the US, leading to a major national shortage.

As clinicians what can we do to about the #IVFluidShortage and how can we prevent this crisis from happening again?

A thread 🧵
1/ Image
There are many things we can do as clinicians to improve ICU care & reduce IVF use.

1️⃣Don't order Maintenance IV Fluid!
Almost no patient actually needs continuous IV fluids.
Most either need resuscitation (e.g. boluses) or can take fluid other ways (PO, feeding tube, TPN).
2/
Frequently if someone is NPO overnight for a procedure, MIVF are ordered.
This is wrong for two reasons.
We are all NPO while asleep & don't need salt water infusions!
We should be letting people drink clears up to TWO HOURS before surgery, per ASA.

3/ pubs.asahq.org/anesthesiology…Image
Read 16 tweets
Nick Mark MD Profile picture
Oct 1
New favorite physiology paper: Central Venous Pressure in Space.

So much space & cardio physiology to unpack here including:
- effects of posture, 3g shuttle launch, & microgravity on CVP
- change in the relationship between filling pressure (CVP) & LV size
- Guyton curves!
1/

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To measure CVP in space they needed two things:
📼 an instrument/recorder that could accurately measure pressure despite g-force, vibration, & changes in pressure. They built & tested one!
🧑‍🚀👩‍🚀👨‍🚀 an astronaut willing to fly into space with a central line! 3 volunteered!
2/
Image
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The night before launch they placed a 4Fr central line in the median cubital vein & advanced under fluoro.

🚀The astronauts wore the data recorder under their flight suit during launch.

🌍The collected data from launch up to 48 hrs in orbit.
3/
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Read 16 tweets
Nick Mark MD Profile picture
Jul 16
The media silence on this is deafening.

Did he have a head CT? What did it show?
Did he have stitches? Tetanus shot?

The NYT ran nonstop stories about Biden’s health after the debate but can’t be bothered to report on the health of someone who was literally shot in the head?
To the people in the replies who say it’s impossible because of “HIPPA”
1. I assume you mean HIPAA
2. A normal presidential candidate would allow his doctors to release the info. This is exactly what happened when Reagan survived an assassination attempt.
washingtonpost.com/obituaries/202…
My advice to journalists is to lookup tangential gunshot wounds (TGSW).

Ask questions like:
- what imaging has he had?
- what cognitive assessments?
- has he seen a neurosurgeon or neurologist?
- he’s previously had symptoms like slurred speech, abnormal gait - are these worse?
Read 4 tweets
Nick Mark MD Profile picture
Jun 30
You've probably heard "don't give lactated ringers because it raises lactate"

This statement is ~98% false, but there's one crucial practice-changing fact that you need to know.

A 🧵 all about lactic acid and lactated ringers!
1/
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First off, we should ackowledge the obvious: Lactated ringers does in fact contain lactate... 28 mEq/L in fact

BUT there's one little detail to remember:
Lactate ≠ Lactic acid

When we measure "lactate" we care about the ACID (H+) which lowers pH & causes organ dysfunction
2/ Image
But the correlation between pH & lactate is really bad!

Look at this analysis of lactate vs pH in 171 ICU patients.

There is a *weak* correlation in people with arterial lactate > 5, but even w/ lactate =10, pH ranged from 7.5 to 7.05. Quite a spread!

3/ ncbi.nlm.nih.gov/pmc/articles/P…
Image
Read 10 tweets
Nick Mark MD Profile picture
Jun 13
If you intubate you need to read the #PREOXI trial!
-n=1301 people requiring intubation in ED/ ICU were randomized to preoxygenation with oxygen mask vs non-invasive ventilation (NIV)
-NIV HALVED the risk of hypoxemia: 9 vs 18%
-NIV reduced mortality: 0.2% vs 1.1%

#CCR24
🧵
1/

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Hypoxemia (SpO2 <85%) occurs in 10-20% of ED & ICU intubations.

1-2% of intubations performed in ED/ICU result in cardiac arrest!

This is an exceptionally dangerous procedure and preoxygenation is essential to keep patients safe.

But what’s the *BEST* way to preoxygenate?
2/
Most people use a non-rebreather oxygen mask, but because of its loose fit it often delivers much less than 100% FiO2.

NIV (“BiPAP”) delivers a higher FiO2 because of its tight fit. It also delivers PEEP & achieves a higher mean airway pressure which is theoretically helpful!
3/
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Read 15 tweets
Nick Mark MD Profile picture
Jun 12
Results from #PROTECTION presented #CCR24 & published @NEJM.
- DB RCT of amino acid infusion vs placebo in n=3511 people undergoing cardiac surgery w/ bypass.
- Reduced incidence of AKI (26.9% vs 31.7% NNT=20) & need for RRT (1.4% vs 1.9% NNT=200)

Potential game changer!

🧵
1/
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I work in a busy CVICU & I often see AKI following cardiac surgery.

Despite risk stratification & hemodynamic optimization, AKI remains one of the most common complications after cardiac surgery with bypass.

Even a modest reduction in AKI/CRRT would be great for my patients.
2/ From Nature reviews nephrology https://www.nature.com/articles/nrneph.2017.119
During cardiac surgery w/ bypass, renal blood flow (RBF) is reduced dramatically. This causes injury, especially in susceptible individuals.

But what if we could use physiology to protect the kidneys?

Renal blood vessels dilate after a high protein meal increasing RBF & GFR!
3/ https://www.jtcvs.org/article/S0022-5223(18)33243-4/fulltext
Read 11 tweets

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