COVID-19 Clinical Discussions with Dr. Marco Garrone & Dr. Peng Zhiyong. #FOAMed

COVID19 has made for a rough start to 2020 for humans. Now ramping up in Canada, we can only hope that lessons learnt in China and Italy by governments and medical teams can be applied in a timely enough fashion to flatten the curve and allow our already stretched-thin healthcare system to absorb it without dire consequences for both COVID and non-COVID patients.

At my shop we have started our (re)organizational plan for the potential storm that may hit us.

So here is my chat with Marco (@drmarcogarrone)

And here is the vidconf audio with Dr. Zhiyong

 

I apologize for the prolonged ending there were technical difficulties and we ended up losing Dr. Zhiyong’s connection at the end.

Some clinical points from these and other discussions:

high compliance ARDS

– needs peep, but avoid hi peep as seems to have high risk of pneumothorax. This may make sense given high compliance may reflect alveolar wall elastic fiber damage.

avoid NIV including HFNC unless negative pressure room to prevent aerosolization.

may need to use N95 for entire duration of rounds in hot zone ICU to save stock

– personally, I would/will consider early proning or modified proning for spontaneously breathing patients (not on NIV either, just face mask).

LUS for screening dx and f/u (see below)

 

Other COVID resources:

Splitting ventilators for multiple patients https://emcrit.org/pulmcrit/split-ventilators/

Covid effects on cardiovascular system https://www.nature.com/articles/s41569-020-0360-5.pdf

Chinese experience with LUS: https://link.springer.com/article/10.1007/s00134-020-05996-6

My friend Jonny Wilkinson (@wilkinsonjonny) put together a great page with a ton of resources here at criticalcarenorthhampton.

My EMCrit Teammates Josh and Scott have put together some great clinical points as well, especially some practical tips for respiratory support setups and airway management.

IBCC a super comprehensive chapter on COVID.

EMCRIT on airway management.

And here are some excellent documents on hospital preparedness, ethics, a ventilatory support infographic from our italian colleagues as well as some kindly shared clinical notes and tips.

covid-19-checklist-hospitals-preparing-reception-care-coronavirus-patients

italian_triage_ethics (1)

ESICM info

SIAARTI – Covid-19 – Airway Management rev.1.1

COVID notes March 11 (1)

Also, as this will undoubtedly be a time for stress for HCPs caring for COVID patients, a respirologist friend of mine shared a link to a wellness/meditation tool, the coronavirus survival guide which has been made freely available to us. Now I have not tried it yet but I trust Andy.

Comment from anaesthetist Dr. Marco Vergone who is on the front line in Turin, Italy:

We are using prone positioning in almost all of our patients that require invasive mechanical ventilation, we’re trying alternate lateral position for patients on CPAP (helmet), and personally I find very promising prone positioning for patients in spontaneous breathing during weaning from CPAP, before discharge from the ICU.
I can confirm that diagnostic (CT and XR) is really burdensome when you have many isolated ICU patients, so lung US becomes paramount for bedside daily evaluation.
We’re working on standardized protocols for different levels of expertise of colleagus (pro level, basic skills, beginners).
For intubation procedures, we perform rapid sequence with ketamine + rocuronium or fentanil+propofol+rocuronium and ALWAYS videolaryngoscope. We always clamp the tube before disconnections and we always sop gas flow before removing helmets of masks. Apart from correct use of PPE, it is paramount to reduce aerosolization and contamination of the environment.
Get prepared ASAP, and stay strong!
Best, M

hope some of this can help other HCPs in these trying times.

 

Philippe