May 18, 2020

Background: Getting the basics right in all illness is vital. In sepsis, this means appropriate use of antibiotics, judicious fluid resuscitation, and early identification.  Vasopressor support is also essential in the sickest sepsis patients (i.e. septic shock). Should the metabolic cocktail (thiamine, vitamin C and hydrocrotisone) be part of that initial package? We’ve previously reviewed the key articles in this area: CITRIS-ALI, VITAMINS, and the original before and after Marik trial. Now we have our next RCT, the HYVCTTSSS trial. From a pathophysiologic standpoint, Vitamin C levels are thought to be low in critically ill patients with sepsis. Vitamin C is an antioxidant that prevents vascular endothelial damage and helps maintain microvascular integrity. Additionally, it is a cofactor for catecholamine synthesis which helps maintain vascular tone and cardiac output.  Glucocorticoids have been shown to reduce time to shock relief and length of ICU stay, but not mortality. The addition of thiamine can help promote oxalate decomposition, which reduces vitamin C metabolites from depositing and crystalizing in kidneys.  While these medications are cheap, the more important question is do they improve patient-oriented outcomes? The previous literature on whether this translates to patient oriented benefits has been mostly negative thus far.

May 17, 2020

There is a lot we still do not know when it comes to COVID-19 pathophysiology. We are learning every day, and as we navigate the waters of the unknown, there are a few that boldly dare to try and understand what is happening in this disease process that may go against mainstream thinking. COVID-19 is new and therefore will require new thinking and new questions but should also be balanced with not grasping for straws and randomly doing things that could be deleterious. Below is a proposed lung injury model that may be right or could be wrong. However, the only way we can further understanding is by feedback and edits until we can get to the right answer. The purpose of this post is not to tell you what you are doing is wrong, but instead putting a model out there so that we can work on this together to find an answer. This is not a recommendation on how to treat patients, but a proposal that needs feedback and work. We felt it was a good starting place for all of us to work together to figure this thing out. Thank you to Dr. Farid Jalali, MD for putting his thoughts down on COVID-19 acute lung injury to help as a starting point.

May 12, 2020

Background: Current management of COVID-19 focuses on supportive care as there are yet to be robust, data driven treatments. To date, there has barely been a glimmer of hope based on published evidence, as most studies are either poor quality or demonstrate “negative” results.  Two more trials have now been published looking at some new options as potential candidates.

May 11, 2020

“You’re in the emergency department, you have a patient who EMS has brought in from a nursing home…who’s excited? Right, nobody is. And they are brought in for a chief complaint of altered mental status. So they’re concerned about sepsis. This is your initial set of vital signs: febrile, tachycardic, hypotensive. And you’re looking at the patient and you’re looking at their Foley and it looks like somebody put oatmeal into it. You know for a fact that the probability is that they have a urinary tract infection is pretty high. So the next question is: do you do what you normally do, but add steroids?”

May 8, 2020

Background: Although Helmet CPAP is not something commonly used in the US, I think its nice to know what other potential options there are to help patients in the midst of a COVID-19 pandemic. Hypoxemic acute respiratory failure (hARF) is a well-known complication that can occur in patients with pneumonia.  This has a high morbidity and mortality associated with it.  An intermediary step prior to intubation is the use of noninvasive positive pressure ventilation (NIPPV) to stave off intubation. A more important question is does NIPPV in patients with pneumonia and hARF improve clinical outcomes? There have been no randomized clinical trials that have evaluated the clinical efficacy of helmet CPAP in patients with pneumonia suffering from hARF to date Helmet CPAP has also gained recent attention as an oxygenation tool for COVID19 pneumonia. The authors of this trial wanted to compare helmet CPAP vs oxygen therapy delivered by Venturi mask to reduce the proportion of patients requiring ETI in hARF due to pneumonia.
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