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 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 6, 2020

There continues to be a slew of publications coming out on a near daily basis in regard to COVID-19.  Some publications will deserve their own posts and others can really be summarized in one or two paragraphs.  In this post I will summarize 5 papers published in the past week, that I found interesting and each has a unique, but important message.  None of these papers are very long, but there are some important aspects of each I felt tied into each other from a cardiovascular standpoint.

May 3, 2020

The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic. The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This post will serve as a summary of emerging available evidence in regard to neurologic manifestations associated with COVID-19.