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Live tweeting #HRreloaded tonight!
First up is COVID intubation and what we've learned from those who faced COVID before us.
Hoo boy there was some drama regarding who should be intubated. PHYSICIANS DIDN'T ALWAYS AGREE IF YOU CAN BELIEVE IT
First up is COVID intubation and what we've learned from those who faced COVID before us.
Hoo boy there was some drama regarding who should be intubated. PHYSICIANS DIDN'T ALWAYS AGREE IF YOU CAN BELIEVE IT
How can we assess how a COVID patient is doing during non-invasive ventilation? How do we judge if they need to be intubated?
The basics
Look at your patient
Look at your team (loads of help and clinical acumen?)
Use your judgment (we can tolerate some hypoxia)
#HRreloaded
The basics
Look at your patient
Look at your team (loads of help and clinical acumen?)
Use your judgment (we can tolerate some hypoxia)
#HRreloaded
In an exciting twist, the next lecture is "How To Not Murder Your Patient with Intubation" this is not to be confused with "How to Get Away with Murder"
#HRreloaded
#HRreloaded
Problems peri-intubation:
1. Medication Effects (Omni here to tell you everything can be a negative inotrope)
2. Loss of endogenous catecholamines
3. Negative to Positive Pressure Ventilation (cardiopulmonary interactions, you guys KNOW this is a thing)
4. Hypoventilation
1. Medication Effects (Omni here to tell you everything can be a negative inotrope)
2. Loss of endogenous catecholamines
3. Negative to Positive Pressure Ventilation (cardiopulmonary interactions, you guys KNOW this is a thing)
4. Hypoventilation
Prepare for decompensation if you were not able to resuscitate before you intubate. If you were able to get some norepinephrine going <insert partay GIF> that's great, if not, get some doses of pressor you can push.
#HRreloaded
#HRreloaded
Next up is ventilation with @adamdavidthomas
He is showing us some batshit crazy stuff from the olden days like rolling patients over a barrel, and blowing smoke up someone's bum, and flogging.
I'm going to go out on a limb and tell you not to do these things.
#HRreloaded
He is showing us some batshit crazy stuff from the olden days like rolling patients over a barrel, and blowing smoke up someone's bum, and flogging.
I'm going to go out on a limb and tell you not to do these things.
#HRreloaded
OMG he's showing us a ripped up alveolus (electron micrograph) and I feel guilty because I know I have hurt some alveoli in my day.
Yikes now a formula that hurts my eyes but suffice it to say that a lot of factors contribute to lung trauma.
#HRreloaded
Yikes now a formula that hurts my eyes but suffice it to say that a lot of factors contribute to lung trauma.
#HRreloaded
Yesterday Lancet reported data for 13,000 ventilated patients. Thee is a signal that driving pressure over 15 hurts patients https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30325-8/fulltext
Goals:
TV 4-8 mL/kg
Plat < 30
PEEP titration
Goal FiO2 < 0.5 (omni here to say good luck with this)
pH > 7.15
Driving Pressure < 15
Mechanical Power < 17 J/min
#HRreloaded
TV 4-8 mL/kg
Plat < 30
PEEP titration
Goal FiO2 < 0.5 (omni here to say good luck with this)
pH > 7.15
Driving Pressure < 15
Mechanical Power < 17 J/min
#HRreloaded
Next up is @iceman_ex to discuss ECMO. Don't let me forget to ask him about severe obesity (BMI > 50) and whether they have difficulties cannulating and managing.
#HRreloaded
#HRreloaded
I'm going to jump in here to say if you want to see how COVID patients are doing on ECMO, check out the ELSO website. You can break it into results by country and adults vs. pediatrics.
https://www.elso.org/Registry/FullCOVID19RegistryDashboard.aspx
#HRreloaded
https://www.elso.org/Registry/FullCOVID19RegistryDashboard.aspx
#HRreloaded
Ok I had to make myself a cheese enchilada with mango salsa. Now I’m back for #HRreloaded speaker @EMNerd_
APRV
(Airway Pressure Release Ventilation)
Is there a central drive to breathe?
Does their diaphragm work?
Are they PEEP dependent?
APRV
(Airway Pressure Release Ventilation)
Is there a central drive to breathe?
Does their diaphragm work?
Are they PEEP dependent?
APRV is like CPAP (that maintains FRC) with a release to drop lung volume to below FRC (that’s how ventilation/removal of CO2 occurs)
Set:
P high (pressure you need for FRC, start at plateau P minus 2)
P low (set @ 0)
T high (time at high pressure)
T low (time at low pressure)
Set:
P high (pressure you need for FRC, start at plateau P minus 2)
P low (set @ 0)
T high (time at high pressure)
T low (time at low pressure)
Feels creepy to set p low to zero, right? That can’t be good for our sweet recruited alveoli. Turns out it never really gets to zero because of how t low is set
T high is the time the patient spends at resting lung volume and has ability to spontaneously breathe.
Sick lungs, T high will be shorter (2)
Better lungs T high longer (4)
T low 0.5
P low 0
P high set at 2 less than plateau pressure
#HRreloaded
Sick lungs, T high will be shorter (2)
Better lungs T high longer (4)
T low 0.5
P low 0
P high set at 2 less than plateau pressure
#HRreloaded
I have to pause here because @DGlaucomflecken wants you to know he was included in the ECMO talk. I am begging you all to avoid asking him ECMO questions, because he will answer them
#HRreloaded
https://mobile.twitter.com/PulmCrit/status/1288616229775847427 https://twitter.com/pulmcrit/status/1288616229775847427
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https://mobile.twitter.com/PulmCrit/status/1288616229775847427 https://twitter.com/pulmcrit/status/1288616229775847427
Lookit, now we’re talking about that little bish the right ventricle. If you remember that the left ventricle gets its blood from the RV, you can find the will to care.
I have a feeling this will be the last conference I am asked to live tweet.
#HRreloaded
I have a feeling this will be the last conference I am asked to live tweet.
#HRreloaded
When you note pulmonary hypertension, you must ask yourself ‘why is this so’
You can make some inferences with RV echocardiography. You have to be good at it, like the guy giving this talk.
#HRreloaded
You can make some inferences with RV echocardiography. You have to be good at it, like the guy giving this talk.
#HRreloaded
So a pt arrives in shock getting a fluid bolus. The doc could tell from these images there was pulm HTN & that the pulm HTN was likely NOT due to the left side of the heart.
He lowers PVR with O2, inhaled milrinone, some other vasodilator and lasix. Pt did well.
#HRreloaded
He lowers PVR with O2, inhaled milrinone, some other vasodilator and lasix. Pt did well.
#HRreloaded
@msiuba is up to talk about #zentensivism
Before you become a minimalist, you must have clinical mastery so you can recognize when it’s appropriate to do less.
The early resuscitation will look similar to every good ICU physician’s early care. The ‘doing less’ is later
Before you become a minimalist, you must have clinical mastery so you can recognize when it’s appropriate to do less.
The early resuscitation will look similar to every good ICU physician’s early care. The ‘doing less’ is later
I become the anti-zentensivist where congenital heart babies are concerned . They are so wiley.
#HRreloaded
#HRreloaded
THIS IS THE END OF MY LIVE TWEET SESSION
Celebrate amongst yaselves
Tomorrow I do a 24 hour call so I probably won’t get to amaze you with my knowledgeable observations of the next session.
Be excellent to each other
#HRreloaded
Celebrate amongst yaselves
Tomorrow I do a 24 hour call so I probably won’t get to amaze you with my knowledgeable observations of the next session.
Be excellent to each other
#HRreloaded
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