1 month w/ #COVID19. Random thoughts.
First, know that only the worst cases of #COVID19 are the ones I see in #ICUIRL. Avoid D.E.A.T.H. It still could be heart failure, COPD, head bleeds, overdoses and everything else. #PrematureClosure #Zentensivist
That in mind, lets go…
1/n

This virus is extracting an exceptionally heavy toll on patients who are obese.
At one point earlier this week 13 of 14 patients I was caring for had BMI >30 (majority well beyond). The other? BMI 29. None were athletes. Age ranges 21-80. Trend has been consistent over month
2/n

#Sedation is hard. Propofol altered hemodynamics at levels to be barely effective. Benzo/Narcotic combos work well but #WesEly was right. Everyone is delirious. #ICUDelirium
3/n

#Ventilators - most for majority of stay are easy to ventilate. Do well when proned. Some % appear to enter a “late fibroproliferative phase" (to borrow from ARDS literature) and become very hard to ventilate. They often die. We have to figure that out. Steroids/IL-6 agents?
4/n

#Hypernatremia
Is sometimes related to free water deficit but mostly FeNa points to “intrinsic renal”. Harder to correct with free water. Which brings me to….
5/n

#AKI - There are casts and various cellular material. There is proteinuria. There are white and red cells. It like like an interstitial nephritis without the eosinophiluria.
6/n

#Hemodynamics are ok. Not much in the way of pressor needs. If you have a #COVID19 patient with pressor needs think sedation induced hypotension or think co-infection. It probably isn't hypovolemia. I’m looking at you #SurvivingSepsis.
7/n

#Nutrition Patients are developing an elevated BUN:Cr ratio in absence of steroids, upper GI bleeding or hypovolemia. I am thinking it is aggressive protein catabolism even with tube feeds.
8/n

#VentWeaning This #COVID19 beast. It is hard to know who will do well once extubated. Most are weaning well 5/5 on PS mode. Have good gasses, 30-35% fiO2. PEEP 5 From there? Some get hypoxic again. Some get hypercapnic. Some do well. Nothing makes sense.
9/n

#Isolation Everyone is isolated, scared. Talk to your patients, even sedated, and let them know where they are, what day it is, who you are, whats wrong with them, that their families are updated and love them, that you are working to make them better. #GetToKnowYouBoard
10/n

#Safety Be safe.

CC: @msiuba @CritCareMD @ogi_gajic @Dr_SRKashyap @covid19registry @DrDaleNeedham @HopkinsMedicine @DrSamuelBrown @medevidenceblog @mkashiouris @siddharth_dugar @PulmCrit +more….

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