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ICU Doctor: Top 10 Things I learned Treating Coronavirus Patients | Coronavirus Intensive Care

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Top 10 Things I learned Treating COVID Patients

Top 10 Things I learned Treating COVID Patients

Some intensive care units in various hospitals throughout this county have designated units for COVID patients. As an intensive care doctor, I’ve seen many COVID patients in our designated Coronavirus ICU. It's one thing to read about Coronavirus in the medical literature, but to be actually seeing real patients with this disease is another experience altogether. I’ve learned many things, but I’ll focus on the top 10 that stand out to me.

⏩ Timestamps, click to skip ahead!
00:00 Top 10 Things I learned Treating COVID Patients

00:36 COVID Symptoms
01:08 Vitamin D deficiency on COVID Patients
02:13 COVID is Contagious
03:53 Lonely at Hospital
04:11 COVID Treatments
07:00 COVID Testing
07:33 A Lot of COVID Patients are obese
09:03 Mechanical Ventilation for COVID
11:02 COVID Recovery
11:53 Unpredictability and Variability

#covid #covid19 #coronavirus
COVID Update Today by Doctor Mike Hansen (YouTube Video Playlist)


So, starting at the bottom with number 10, is, signs/symptoms. The most common COVID symptoms that I’m seeing are fever, cough, shortness of breath, and body/muscle aches. I haven’t seen many patients with the other symptoms we often hear about, such as loss of taste and smell, nausea, and diarrhea. I have not seen any rashes related to COVID, probably because I only see adult patients. I will say that even though confusion and delirium are widespread in the ICU in general, there does seem to be more of that with Coronavirus.

A lot of COVID patients who require hospitalization have low levels of vitamin D, And this is consistent with what we are seeing in a lot of recent studies that have been coming out. But of course, correlation doesn’t necessarily mean causation, so does it just so happen that many patients with moderate or severe COVID happen to have low vitamin D levels? Maybe, maybe not.
And does that mean that we should give every hospitalized patient with Coronavirus big doses of vitamin D when they hit the door? Maybe.
And does that mean people, in general, should supplement with vitamin D? And what is the ideal level of vitamin D for the population, especially when it comes to COVID? Should we target the current general recommendation for everyone, irrespective of COVID, with a goal of 20 mg/ml? Or should we aim for higher, like 30, or perhaps 40? No one knows for sure the answers to these questions. But studies are being done on this. And as we speak, there are 3 RCT for vitamin D and Coronavirus.

Coronavirus is VERY contagious. One of my patients was in the hospital for unrelated reasons. She actually had sepsis due to an infarcted gut, meaning part of her intestine was not getting enough blood flow. It was severe enough to the point that some of the tissue in her intestine had died. When this happens, the bacteria that live in the intestine can then invade the walls of the intestine and get into the bloodstream. This is bad news because these bacteria can then spread throughout the body, known as sepsis. Besides antibiotics, this treated with surgery, where the dead gut tissue is removed, meaning part of the intestine is taken out. And this is what happened to her. And she got better. But after she initially got better, she started having more difficulty with her breathing. Her oxygen levels were dropping, despite us giving her more and more oxygen. So we got a CXR and later a CT scan of the chest, which showed bilateral infiltrates, meaning areas of inflammation in both lungs. And this is the pattern we typically see with COVID pneumonia, where it tends to go to the periphery of the lungs and more so at the bottom of the lungs.

Vitamin D3 (Cholecalciferol) and Vitamin D2 (Ergocalciferol) and Calcitriol
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Does Vitamin D help with Immunity?
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Doctor Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine
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#covid #covid19 #coronavirus
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How to Treat COVID 19 Patients in the ICU

How to Treat COVID 19 Patients in the ICU
COVID 19 has brought unprecedented challenges regarding the ability to generate timely evidence, all while this pandemic overwhelms hospitals and health care workers.
About 5% of patients with covid 19 require admission to the intensive care unit and mechanical ventilation.
Based on the recent epidemiological models, COVID is going to hit all the areas in the USA.

Every ICU is preparing for the surge. There are several changes that intensive care units are making, including ours.


#covid #covid19 #coronavirus
COVID Update Today by Doctor Mike Hansen (YouTube Video Playlist)


We prepare anesthesiologists (who are not CCM trained) and nurse anesthetists to manage patients with COVID 19. Even though they are not CCM trained, we have a lot of overlap of knowledge, especially when it comes to managing ventilators, and we have a lot of overlap with certain procedures.

Allowing anesthesiologists and nurse anesthetists to help in this manner will help other intensivists like myself handle the surge of patients coming our way.

And because they are helping us, that is the main reason for me making this video, so that they can watch this and be better equipped to handle the surge with us.

“Knowing and implementing all of the info in this video does not guarantee you save a COVID 19 patient living in the ICU, but it will give you the best chance of doing so.”

If a patient with COVID is coming to your ICU, they most certainly have pneumonia, and they probably have acute respiratory distress syndrome (ARDS) as well.

Patients with severe disease who require ICU admission are likely to have high oxygen requirements.
Although both High flow oxygen and noninvasive positive pressure ventilation have been used for COVID 19, their safety is uncertain. They are considered aerosol-generating procedures that warrant specific isolation precautions.

Most patients who require ICU admission have ARDS, and they will likely have a better outcome if intubated sooner rather than later. That is another reason why it likely better to skip Hi-Flow oxygen and NIPPV and jump straight to intubation.

Acute Respiratory Distress Syndrome (ARDS)
ARDS is a clinical diagnosis based on non-cardiogenic pulmonary edema, with bilateral patchy infiltrates on chest imaging and a PaO2/FiO2 ratio of less than 300.

In ARDS, this crazy, chaotic inflammatory response within the lungs, with damage to the alveoli and surrounding capillaries, leads to excess protein and fluid accumulation in interstitial and alveolar spaces.

That means decreased lung compliance, increased V̇/Q̇ mismatch, and increases in shunt and dead-space ventilation.

Patients with ARDS are at high risk of mortality, which increases with ARDS severity. With that said, mortality is usually the result of the underlying disease that triggered ARDS, rather than refractory hypoxemia.

The severity of ARDS is important because it’s going to determine how we manage patients with ARDS.

With ARDS, the alveoli fill up with protein and fluid. This leads to at least partial alveolar collapse and decreased lung compliance with shunt physiology.

Increasing the PEEP minimizes the repeated opening and closing of distal airways and alveoli. It also improves the homogeneity of the lung parenchyma by reducing drastic differences in regional lung compliance.

What is the ideal level of PEEP?
No one knows for sure. Typically for ARDS, we set the initial PEEP between 10 to 15. Sometimes all the way to 20 if they have severe disease. You don’t want to go too high, though, because this increases the risk of pneumothorax.
The recommendation is to give COVID 19 patients steroids only if they have ARDS.

Critically ill patients with COVID often develop septic shock. And for shock, we give IVF and vasopressors. But ARDS patients generally do better when you keep them in a negative fluid balance state.

COVID 19 patient, who is in shock and ARDS, what should you do?
Based on my experience of treating ARDS patients in shock, my recommendation would be to use minimal fluid and start vasopressors early. In my experience, patients tend to respond better to albumin than crystalloids, especially if they have low albumin levels. Either way, you’re going to want to assess fluid resuscitation responsiveness, and if they don’t respond well to fluids, just stick with the vasopressors.

Note: To get the proper details, please watch the video from first to last without skipping.

Doctor Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine
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#covid #covid19 #coronavirus
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Topics discussed in this interview:
0:00 Introduction

2:00 Say you have 100 patients come into the hospital with COVID-19. It looks like about a third end up in the intensive care unit. How do they do once they're in the intensive care unit?

7:00 There's been some tension about early intubation versus waiting. Do you want to comment on that or just not enough information?

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26:45 Do you understand the exuberance around chloroquine?

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32:10 Visitation is remarkably limited and their loved ones are dying and are going to die. Either they're on a ventilator or they've been appropriately extubated to spend their last few hours in comfort. How do you imagine that playing out in the US?

38:39 How soon do you think we'll get results from the randomized trials?

40:58 What is the primary outcome in most of the trials?

41:52 Would you use one ventilator for two patients if ventilators are scarce?

42:45 What do you think the 900,000 physicians who aren't intensivists need to know?

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Critical Care Management of COVID-19 Patients (Faisal N. Masud, MD) April 16, 2020

LIVESTREAM RECORDING
April 16, 2020
HMDHVC GRAND ROUNDS CONFERENCE

Critical Care Management of COVID-19 Patients: What Non-Intensivist Need to Know

Houston Methodist DeBakey Heart & Vascular Center, Grand Rounds Conference featuring Faisal N. Masud, MD, Deepa Gotur, MD, Daniela M. Moran, MD, Divina M. Tuazon, MD, and Steven H. Hsu, MD, as they discuss “Critical Care Management of COVID-19 Patients: What Non-Intensivist Need to Know.

INTRODUCTION: Dipan J. Shah, MD

MODERATOR: Faisal N. Masud, MD, FCCP, FCCM
Medical Director, Center for Critical Care, Houston Methodist Hospital
Vice Chair for Quality and Patient Safety, Professor of Clinical Anesthesiology
Medical Director, CVICU, Houston Methodist DeBakey Heart & Vascular Center

PANELIST: Steven H. Hsu, MD
Daniela M. Moran, MD
Deepa Gotur, MD
Divina M. Tuazon, MD
_________________________________
Presented by Houston Methodist DeBakey Heart & Vascular Center.

A DeBakey CV Education event

Building on Dr. Michael E. DeBakey’s commitment to excellence in education, Houston Methodist DeBakey CV Education is an epicenter for cardiovascular academic and clinical educational programs that support the provision of optimal care to patients suffering from cardiovascular conditions and diseases.

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Ivermectin and COVID 19

Ivermectin



Invitro antiviral activity

Against a broad range of viruses

HIV, dengue, influenza, Zika virus

Invitro antiviral, SARS-CoV-2 activity

99.8% reduction in viral RNA after 48 h

Worldwide use for treating COVID-19

About 3.7 billion doses of ivermectin have been distributed globally over the past 30 years

EVMS CRITICAL CARE COVID-19 MANAGEMENT PROTOCOL



Preexposure prophylaxis in high-risk patients

Postexposure prophylaxis

Symptomatic patients at home

Mildly symptomatic patients in hospital

Progressive Respiratory symptoms

Ivermectin has emerged as the “wonder drug” to prophylaxis and treat COVID-19

Ivermectin inhibits viral replication and has potent anti-inflammatory properties

There is the potential for serious drug-drug interaction

Additional, studies are urgently required to confirm these very impressive preliminary findings

Review of the Emerging Evidence Demonstrating the Efficacy of Ivermectin in the Prophylaxis and Treatment of COVID-19 (7th December)



Front Line COVID-19 Critical Care Alliance (FLCCC)

One Sentence Summary

Review of recently available clinical trial results demonstrating efficacy of ivermectin in prophylaxis and treatment of COVID-19.

Use of Ivermectin Is Associated With Lower Mortality in Hospitalized Patients With Coronavirus Disease 2019

The ICON Study (October 2020, South Florida)



Research Question

Does ivermectin benefit hospitalized coronavirus disease 2019 (COVID-19) patients?

Study Design and Methods

Consecutive patients hospitalized

Four hospitals in Florida

Confirmed COVID-19

March 15 and May 11, 2020

Treated with or without ivermectin

Primary outcome

All-cause in-hospital mortality

Secondary outcomes, mortality in patients with severe pulmonary involvement, extubation rates for mechanically ventilated patients, length of stay

Severe pulmonary involvement

Need for Fio2 ≥ 50%, noninvasive ventilation

Invasive ventilation

Results from reviews

N = 280

Ivermectin treated = 173

Overall mortality 15%

Mortality with severe pulmonary involvement = 38.8%

Not given ivermectin = 107

Overall mortality 25% (OR, 0.52)

Mortality with severe pulmonary involvement = 80.7%

No significant differences were found in extubation rates or length of stay

Most patients in both groups also received hydroxychloroquine, azithromycin, or both

Interpretation

Ivermectin treatment was associated with lower mortality during treatment of COVID-19

Especially in patients with severe pulmonary involvement

Randomized controlled trials are needed to confirm these findings

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