April 19, 2020

Many facilities are using COVID-19 screening protocols to determine how to cohort patients in the ED. Although this sounded like a good idea initially, this strategy is destined to fail.  Early on in the pandemic, we thought we could identify potential COVID-19 patients based on the presence of fever and cough. However, multiple studies are coming out showing a high prevalence of asymptomatic patients with positive tests for SARS-CoV-2.  Identifying asymptomatic patients is important to improve outpatient quarantine (i.e. maximize physical distancing) and to improve staff safety (i.e. incorrectly admitting patients to the wrong area of the hospital). In most regions, there are simply not enough tests to test everyone, but a universal testing strategy needs to be implemented, especially for admitted patients as this can have major ramifications to staff and patient safety.

April 9, 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 new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target.  This post will serve as a summary of thrombosis and hemoglobin in regard to COVID-19.

April 5, 2020

Hey there REBEL Cast listeners, Salim Rezaie here.  For me and I am sure many COVID-19 has been quite the whirlwind.  So much information, so little time to process all of it.  Meanwhile, many of us are on the frontlines having to take care of these patients.  Personally, I have never been so wrong, so many times about a single disease process.  What I say today, may be different tomorrow.  This podcast was recorded on April 3rd, 2020 so any information that comes out after this, might change the viewpoints that are expressed today.

March 31, 2020

I have been thinking a lot about patients with COVID-19 and the pulmonary pattern that they develop.  This disease process has been categorized like ARDS, but the reality is it is not like "typical" ARDS.  Lung compliance is often normal in these patients, and many patients are not in respiratory distress despite low O2 saturations.  Patients can have a bizarre hypoxemia that does not correlate with their symptoms.  I have even read reports of patients looking comfortable and speaking in full sentences with oxygen saturations in the 40 – 80% range.  There are also more traditional patients in respiratory distress with similar oxygen saturations.  This is a situation where we cannot treat a patient based solely on a number - pulse oximetry may not be a reliable marker of respiratory compromise.

Approaches to oxygen supplementation have stressed minimizing aerosolization of viral particles by avoiding HFNC and NIV.  This appears to be a fear-based statement as opposed to an evidence based one.  If we go straight from nasal cannula to intubation, we will simply run out of ventilators.  Then, more challenges present themselves like rationing mechanical ventilation and trying to figure out how to split ventilators due to the lack of resources.

Finally, I have yet to find a study that shows a mortality rate <50% once a patient is intubated.  Maybe a better way to deal with these patients is an intermediary step using HFNC or CPAP while proning patients while they are awake, before considering intubation.  In this post, I want to review some evidence to support my thoughts on this and, just assume that in every scenario we are discussing full PPE (eye protection, N95/PAPR, gown, gloves, and face shield).

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.
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