COVID-19: Airborne or Droplet Precautions

This is a widely contested topic that I feel we still do not know the full answer on, but I am feeling better about.

As of right now, though, it seems hospital administrators have a leg to stand on when they recommend face masks for the majority of cases and N95's/respirators for NIV, intubations, bronchs, nebs, etc. I don't know if this is an official recommendation by any agency, but patients who have COVID-19 or are being ruled out for this should wear a mask in the hospital and outside the hospital. 

The flip flopping of policies occurs as we learn more data. It seems shady to me that they flipped their policies as shortages occurred, but it seems as if it's defensible at this time.

WHO: The February 27, 2020 guidance paper states:

"Healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask and eye protection (goggles or face shield)."

"Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy) healthcare workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant."

CDC: updated recommendations on March 10, 2020:

"Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand.
During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP."

Essentially, they are acknowledging that we are being put at risk due to the lack of masks.

The most recent stir and adding to the controversy was a recent publication NEJM published on 3/17/20 which states:

"SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours)"

"The half-lives of SARS-CoV-2 and SARS-CoV-1 were similar in aerosols, with median estimates of approximately 1.1 to 1.2 hours"

"Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed)"

The key point is that the authors went out of their way to both nebulize the virus AND fed it into a Goldberg drum to further disperse it (I don't know what that is and google wasn't too helpful).

It is admittedly outside my scope of knowledge how to interpret the titers in the air, but it seems as if it's there and transmissible to us, the boots on the ground. I cannot make a concrete declaration based on my level of knowledge. I'd welcome your interpretation. I am curious to see how the ever-intelligent people in the CDC and WHO react to this data and possibly adapt their recommendations. 

We should also reach out to the local news agencies to assist us in asking the N95 hoarders to donate their extras to the local hospitals. We need to protect each other. 

-EJ

Link to the WHO Interim Guidance Paper

Link to the CDC Information

Link to the NEJM Abstract

Link to the NEJM PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

How to take off your PPE after caring for COVID-19 patients

The first time I walked into a the room of a patient with suspected COVID-19 I was very methodical with every step. I had done my required reading. I had an N95, a face shield over that, a hair net, the stupid yellow contact gown, double gloves. At the same time I felt naked. I had seen the people on TV and in other countries in basically hazmat suits. The uncertainty was driving me bonkers but I needed to take care of the patient ASAP. The nurse and I got everything together and we went in. We took care of the patient. When it was time to come out, the same methodical steps took place. But somewhat in reverse. It’s hot in there with all that gear when you have to put on the sterile gown for procedures and the sterile gloves on top of my double gloves. Since the I have walked into a number of rooms and am getting the feeling that this is going to be the new normal for the next few months. I felt it was important to do a second post today to share the CDC guidelines on how to put on and take off the personal protective equipment. I have attached the images from this as well. Feel free to share with your friends.

I was inspired to create this post after seeing @doctorwarsgame’s similar post. I must give him credit. I also sent meme, as I am not someone who creates them on this medium, to @bedsideroundz for his approval. He actually was the one who suggested that I use it to teach people the correct way to do it.

Thank you all for your support.

CDC Guidelines for Healthcare Personnel PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Airway pressure release ventilation

We are already seeing severe ARDS from these patients infected with COVID-19. There's discussion out there regarding VV-ECMO, proning, and numerous other strategies to help oxygenate and ventilate our patients. There are numerous different modes on the ventilator to help us achieve these goals but I have found none to be more polarizing than airway pressure release ventilation which is also called APRV. On the Servo vents this is called BiVent (just adding to the confusion of terminology).

Since we are in the process of contemplating providing our patients with anti-retrovirals and anti-malarial drugs, I feel that some of us should reach out of our comfort zone and familiarize ourselves with APRV. If I'm being completely honest, I haven't needed this mode of ventilation much since fellowship. I haven't had many patients in whom I have had such a hard time oxygenating them where I have to reach for this mode. I tend to paralyze patients which is definitely NOT recommended in patients with APRV therefore ameliorating the benefit. I am aware of the PETAL study (Early Neuromuscular Blockage in the ARDS, NEJM 5/2019) which did not show a benefit to paralytics, by the way. My experience is therefore limited, thankfully for my patients who haven't needed me to venture down this road.

The data for APRV is not the most robust, but this recently published review this month contains some great tables and recommendations including the indications and contraindications for APRV, how to set up the vent to initiate APRV, how to troubleshoot the vent depending on the different physiological derangements (I find hypercapnia to be the most common of these personally), and lastly how to wean the vent. I feel the authors did a great job and definitely a good resource to have in your article collection. Stay safe everyone!

A hat tip to the authors.

-EJ

Link to Abstract

Link to FULL FREE ARTICLE

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

COVID-19: Don't order unnecessary nebulizations!!

Colleagues, I know that lots of us have knee-jerk tendencies to order nebulizations on everyone who is on a ventilator, NIV, or any type of shortness of breath under the sun because it makes us feel warm and fuzzy inside where we say "I did something". This behavior needs to stop. We are potentially aerosolizing the virus and putting our teammates at risk. COVID-19 does not appear to be an airborne virus, it is a droplet precaution virus. We need to take care of our patients but we can't go down ourselves. Let stop with the unnecessary tests and treatments. We should not have our respiratory therapists and nurses being unnecessarily exposed, simply the process of going in and out of the room, for no beneficial reason to the patient. We're at war here. We need all of our soldiers intact to help us in this fight. Stop the unnecessary practices.

This data is pulled from the SARS outbreak. Both of these articles are free.

- EJ



Link to FULL FREE Article


Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet. 2003;361(9368):1519–1520. doi:10.1016/s0140-6736(03)13168-6



Link to FULL FREE Article

Loeb M, McGeer A, Henry B, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis. 2004;10(2):251–255. doi:10.3201/eid1002.030838

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

US Ventilator Resources for COVID-19

I have purposefully kept quite and obtained data regarding the COVID-19 outbreak. I don't like to open my mouth or write unless I have a pretty good grasp on what is going on. My crew and I are going to be on the front lines when this thing hits, and I believe it's going to hit. I hope I'm wrong. The majority of the people who follow my page are going to be on the front lines, too. That being said, the system is going to be stressed for resources. I have already heard from different regions of the country and I'm concerned. 

The Society of Critical Care Medicine just sent out an email discussing resource availability. 
I'm more concerned after reading this letter. The data is extremely outdated in many parts. The numbers are obtained from the American Hospital Association which were obtained via voluntary survey. Here's an example: in 2009 we had, in the country, 62000 vents. We have almost 99000 old vents (I don't know what this means nor where they are bc they mention that 23k are NIV, 33k are automatic resuscitators, and 8500 are CPAP units). The strategic national stockpile has 8900 ventilators ready for deployment. 

We're looking at an estimated total of 200,000 ventilators in the country. 

They crunched the numbers based on the number of people who end up on the vent with COVID-19. We could reasonably expect 960,000 to require ventilatory support. I don't know if ventilatory support means non-invasive ventilation + high flow nasal cannula + mechanical ventilation or just MV. I've read about avoiding NIV and HFNC as they aerosolize the virus but I need to learn more. 

It's great to see that we have more critical care beds per capita than anywhere else in the world, but who is going to take care of those patients when there's a limited supply of healthcare professionals who are trained to take care of the critically ill? 

I see this as us being in deep trouble and that all the lockdowns, travel bans, cancellations of everything being justified. My respect for this is growing as I become more educated. I was supposed to go to Greece on Monday. I was bummed out but I reminded myself that this is not about me. 

Stay safe, everyone. 

-EJ

Link to PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Intravenous Fluid Lecture: Citations

I have been missing for a few weeks as I am putting the finishing touches on my lectures that are due on the 15th of this month. The amount of time and effort necessary to write a CME lecture is insane. I've written 7 of them in this last year. Voluntarily, of course. I'm not complaining. For my intravenous fluid lecture, I have cited 43 different articles listed below. I have attempted to cite these articles as well as I know how to but there will be some inevitable errors. If you plan on creating an IVF lecture of your own, this is my gift to you. My only request is that you credit me in some way, shape, or form. Ultimately, I did not write any of these articles. I have to tip my hat to everyone who contributed to the writing of all of these articles. They are the ones who did the leg work and I am ultimately piggybacking on their efforts. 

This lecture discusses the three fluids we use for resuscitation in critically ill patients: 0.9% NaCl, Lactated Ringers, and Plasma-Lyte. I go over the history of the three fluids, and also break down the contents of these fluids, based on the data on how they affect our patients and our organs, then present the relevant data on how these data changes outcomes in our critically ill patients. The reason why this is a controversial topic is because most clinicians use saline because they really do not understand what is in it, nor the effects of it. As I mention in one of my slides, if the FDA had to approve 0.9% NaCl today, chances are that it would not be approved. 

I am sorting out how to provide you all with this lecture, youtube or some other medium. The issue is that youtube has a thing for demonetizing my videos the moment I say the words "mortality", "death" and others. I do earn some income from you all visiting my website, eddyjoemd.com to check out the links and download the articles I share. Thank you all for your support! 

-EJ

Citations:

Lobo DN, Stanga Z, Aloysius MM, et al. Effect of volume loading with 1 liter intravenous infusions of 0.9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: a randomized, three-way crossover study in healthy volunteers. Crit Care Med. 2010;38(2):464–470. doi:10.1097/CCM.0b013e3181bc80f1

Link to Abstract

Ragaller MJ, Theilen H, Koch T. Volume replacement in critically ill patients with acute renal failure. J Am Soc Nephrol. 2001;12 Suppl 17:S33–S39.

Link to Abstract


Link to FULL FREE Article

Bark BP, Persson J, Grände PO. Importance of the infusion rate for the plasma expanding effect of 5% albumin, 6% HES 130/0.4, 4% gelatin, and 0.9% NaCl in the septic rat. Crit Care Med. 2013;41(3):857–866. doi:10.1097/CCM.0b013e318274157e

Link to Abstract

Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr. 2001;20(2):125–130. doi:10.1054/clnu.2000.0154

Link to Abstract

Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008;27(2):179–188. doi:10.1016/j.clnu.2008.01.008

Link to Abstract

Lewins, Robert. Injection of Saline Solutions into the Veins. (1832). The Boston Medical and Surgical Journal, 6(24), 373–375.

Link to Abstract

Link to FULL FREE Article

Hartmann AF, Senn MJ. STUDIES IN THE METABOLISM OF SODIUM r-LACTATE. II. RESPONSE OF HUMAN SUBJECTS WITH ACIDOSIS TO THE INTRAVENOUS INJECTION OF SODIUM r-LACTATE. J Clin Invest. 1932;11(2):337–344. doi:10.1172/JCI100415

Link to Abstract


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Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

Link to Abstract


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Rizoli S. PlasmaLyte. J Trauma. 2011;70(5 Suppl):S17–S18. doi:10.1097/TA.0b013e31821a4d89

Link to Abstract


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Brown RM, Wang L, Coston TD, et al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019;200(12):1487–1495. doi:10.1164/rccm.201903-0557OC

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Li H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181–187. doi:10.1631/jzus.B1500201

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Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Invest. 1983;71(3):726–735. doi:10.1172/jci110820

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Quilley CP, Lin YS, McGiff JC. Chloride anion concentration as a determinant of renal vascular responsiveness to vasoconstrictor agents. Br J Pharmacol. 1993;108(1):106–110. doi:10.1111/j.1476-5381.1993.tb13447.x

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Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers [published correction appears in Ann Surg. 2013 Dec;258(6):1118]. Ann Surg. 2012;256(1):18–24. doi:10.1097/SLA.0b013e318256be72

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McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg. 2013;117(2):412–421. doi:10.1213/ANE.0b013e318293d81e

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Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369(13):1243–1251. doi:10.1056/NEJMra1208627

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Noritomi DT, Soriano FG, Kellum JA, et al. Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med. 2009;37(10):2733–2739. doi:10.1097/ccm.0b013e3181a59165

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Neyra JA, Canepa-Escaro F, Li X, et al. Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients. Crit Care Med. 2015;43(9):1938–1944. doi:10.1097/CCM.0000000000001161

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Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care. 2016;20(1):315. Published 2016 Oct 6. doi:10.1186/s13054-016-1499-7

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Modi, MP. A comparative study of impact of infusion of Ringer's Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation.Saudi J Kidney Dis Transpl. 2012 Jan;23(1):135-7.

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Khajavi MR, Etezadi F, Moharari RS, et al. Effects of normal saline vs. lactated ringer's during renal transplantation. Ren Fail. 2008;30(5):535–539. doi:10.1080/08860220802064770

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Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient. Surg Clin North Am. 2012;92(2):189–vii. doi:10.1016/j.suc.2012.01.004

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Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88(10):1127–1140. doi:10.1016/j.mayocp.2013.06.012

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Ichai C, Orban JC, Fontaine E. Sodium lactate for fluid resuscitation: the preferred solution for the coming decades?. Crit Care. 2014;18(4):163. Published 2014 Jul 7. doi:10.1186/cc13973

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Farkas, Josh. “Three myths about Plasmalyte, Normosol, and LR” https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/\.1/26/15

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Nalos M, Leverve XM, Huang SJ, Weisbrodt L, Parkin R, Seppelt IM, Ting I, Mclean AS: Half-molar sodium lactate infusion improves cardiac performance in acute heart failure: a pilot randomized controlled clinical trial. Crit Care 2014, 18:R48.

Link to Abstract

Link to FULL FREE Article

Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

Link to Abstract


Link to FULL FREE Article

Yartsev, Alex. Metabolic Fate of Lactate, Acetate, Citrate and Gluconate. http://www.derangedphysiology.com/main/core-topics-intensive-care/manipulation-fluids-and-electrolytes/Chapter%204.1.4/metabolic-fate-lactate-acetate-citrate-and-gluconate. Accessed 3.13.2020

Spriet I, Lagrou K, Maertens J, Willems L, Wilmer A, Wauters J. Plasmalyte: No Longer a Culprit in Causing False-Positive Galactomannan Test Results. J Clin Microbiol. 2016;54(3):795–797. doi:10.1128/JCM.02813-15

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Stocker RA. "Normal" Saline and Co: What Is Normal?. Crit Care Med. 2016;44(12):2282–2283. doi:10.1097/CCM.0000000000002030

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Zampieri FG, Ranzani OT, Azevedo LC, Martins ID, Kellum JA, Libório AB. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. Crit Care Med. 2016;44(12):2163–2170. doi:10.1097/CCM.0000000000001948

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Shaw AD, Bagshaw SM, Goldstein SL, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012;255(5):821–829. doi:10.1097/SLA.0b013e31825074f5

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Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. Crit Care. 2015;19(1):286. Published 2015 Aug 28. doi:10.1186/s13054-015-1011-9

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Ince C, Groeneveld AB. The case for 0.9% NaCl: is the undefendable, defensible?. Kidney Int. 2014;86(6):1087–1095. doi:10.1038/ki.2014.193

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Hammond NE, Taylor C, Saxena M, et al. Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013. Intensive Care Med. 2015;41(9):1611–1619. doi:10.1007/s00134-015-3878-y

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Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011;29(6):670–674. doi:10.1016/j.ajem.2010.02.004

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McFarlane C, Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia. 1994;49(9):779–781. doi:10.1111/j.1365-2044.1994.tb04450.x

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Young JB, Utter GH, Schermer CR, et al. Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial. Ann Surg. 2014;259(2):255–262. doi:10.1097/SLA.0b013e318295feba

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Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial [published correction appears in JAMA. 2015 Dec 15;314(23):2570]. JAMA. 2015;314(16):1701–1710. doi:10.1001/jama.2015.12334

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Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018;378(9):819–828. doi:10.1056/NEJMoa1711586

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Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

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Young PJ. Balanced Crystalloids or 0.9% Saline in Sepsis. Beyond Reasonable Doubt?. Am J Respir Crit Care Med. 2019;200(12):1456–1458. doi:10.1164/rccm.201908-1669ED

Link to Abstract


Link to FULL FREE Article

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Upcoming Lectures

The following are places where I am going to be doing my lectures in the upcoming months:

2020

April 4: Ponte Vedra Beach, FL: Link to Program
Innovations in Cerebrovascular Science Conference: Topic "Pulmonary Disorders in Acute Neurological Injury"
Cancelled. 

May 14: West Palm Beach, FL: Link to Program 
Topics: Fluids and Metabolic Resuscitation, Lactic Acidosis, NIV and HFNC
Cancelled.

May 25-29: Maui, HI: Link to Program
Topics: Metabolic resuscitation, Lactic Acidosis, nutrition and gut health, non-opioid pain management, vasopressors, NIV and HFNC, IV Fluids
Cancelled.

August 20-23: Portland, OR: Link to Program
Topics: Cardiogenic shock, resuscitation, HFNC and NIV, nutrition and gut health, lactic acidosis, vasopressors, metabolic resuscitation

October 5-7: Philadelphia, PA: Link to Program
ResusX. Topics to be determined

2021

May 20-23: Brooklyn, NY: Link to Program
Topics: Cardiogenic shock, vasopressors, steroids and metabolic resuscitation, nutrition and gut health, non-opioid pain management, HFNC and NIV, lactate and IV fluids

Reach out to me if you're interested in me coming to your shop to do a Grand Rounds or some sort of presentation. 

Hope to see you all soon! 
-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.