March 22, 2020

Background: The Surviving Sepsis Campaign published their recommendations for the management of patients with COVID-19 on March 20th, 2020 (though as of the date of this blog post, the document has not been peer reviewed).  36 experts from 12 countries attempted to answer 53 questions that are relevant to the management of COVID-19 patients in the ICU. 54 recommendations were made of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations.  Finally, no recommendations were provided for 6 of the questions.  The document is divided into 5 sections:
  1. Infection Control
  2. Laboratory Diagnosis and Specimens
  3. Hemodynamic Support
  4. Ventilatory Support
  5. COVID-19 Therapy
Below is the list of recommendations and I will interject my thoughts on the ones that need them.

March 21, 2020

Background: Since the introduction of SARS-CoV-2 to the world in December 2019, there have been no medications approved or proven effective for the treatment of this pandemic. Lopinavir is an HIV protease inhibitor that is combined with Ritonavir to increase its half-life.  This combination of medications has also been studied in severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) and showed promising results. This makes it a research target for COVID-19.  Many of us are awaiting a treatment that works against SARS-CoV-2 and badly want/need a treatment that is safe and effective. In this publication the authors evaluated the efficacy and safety of oral lopinavir-ritonavir for SARS-CoV-2 infection in adult patients hospitalized with severe COVID-19.

March 20, 2020

On Feb 21st, a patient by the name of Aldo, a 72-year-old male, came to our ED with fever and progressive dyspnea. In addition, his chest x-ray showed an interstitial pattern. It was on this day that COVID19 had arrived in our emergency department… In this post we will describe how we responded to the COVID19 challenge, the impressive number of patients seen in just a few days’ time and some suggestions to prepare your emergency department for the future.

March 19, 2020

Background: Vasopressors are often used to improve hypotension and perfusion in an effort to decrease mortality of patients with septic shock. Mean arterial pressure (MAP) of >65mmHg has typically been used to guide vasopressor therapy in most patients and higher targets have been recommended for patients with chronic hypertension or coronary artery disease. Results from the Sepsis and Mean Arterial Pressure (SEPSISPAM) [2] and Optimal Vasopressor Titration (OVATION) [3] pilot trials suggested that increased exposure to vasopressors targeting higher MAPs in older patients (≥65mmHg) may be associated with increased risk of death. We now have the 65 trial [1] which is a randomized clinical trial testing the hypothesis that reducing vasopressor exposure through permissive hypotension (Targeting a MAP of 60 – 65mmHg) among patient ≥65 years of age with vasodilatory hypotension versus usual care in the ICU.

March 2, 2020

Background: The cornerstones of sepsis management include early identification, early antimicrobial administration, and source control.  The Surviving Sepsis Campaign guidelines recommend that blood cultures be drawn before starting antimicrobial therapy, however, obtaining cultures prior to antibiotics may be challenging due to shorter time windows (i.e. 1hr from identification) to initiate antibiotics.  Some may prioritize administering antimicrobial agents before obtaining blood cultures to ensure they meet this core measure. This study (The FABLED Trial) tried to determine the sensitivity of blood cultures obtained both before and after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.