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4/2/2020: COVID-19 Symposium II - Shared screen with speaker view
pratikv
01:17:01
also, could you do a mic check please?
andrewgraustein
01:27:04
WA state predicted peak was April 24th on Monday, April 19th on Tuesday, now April 11th today all from the same website. I wonder what has been changing to cause that shift.
Weston Powell
01:27:41
The data is based on confirmed deaths- since the last few days have had wide swings in number of deaths (27 down to 4) that is skewing the model
andrewgraustein
01:28:30
@Weston Powell: thanks!
Weston Powell
01:28:30
The model fits a curve to current death rate curve, so changes in the early part of the curve will have big changes in the shape and therefore the peak date.
Alex Bryant
01:28:31
I think people should be aware that the IHME modelling approach has several limitations which are well discussed by others at UW (twitter and elsewhere), including dependence on lagging death rates, and several assumptions about growth rate / isolation effects.
Basak Coruh
01:28:49
Agreed, only a starting place and anticipate it will continue to change
Molly Billings
01:30:15
How many actually get off the ventilator at all (not via comfort care)? I imagine this varies by age/comorbidity dramatically but may be important as resources become limited.
Hassan
01:30:58
also depends on how high/low your threshold is in terms of who you intubate
Sharukh Lokhandwala
01:31:09
I think the early data we have might be a bit skewed by the early cohort being very comorbidly ill
Sharukh Lokhandwala
01:31:38
Working on collecting data for more recent patients, but anecdotally outcomes are improving compared to the first 3 weeks
Hugo Carmona
01:31:47
agreed, such an important question but it doesn’t seem we’re just at the place of having enough longitudinal data
Mohammed Nayeemuddin
01:32:00
Yea, there was a conference last week with physicians from Wuhan. They were intubating anyone who required > 6 liters of oxygen. That may explain their 5 day extubation timeline
mark
01:32:32
In surveying local ICUs, about 30 successful extubations have been reported, with median time on vent around 10 days. Thus far, only 3 of those reported extubations has been in patients 75 or older.
Hugo Carmona
01:32:41
@Sharukh: Mark Sullivan from Swedish also presented similar hopeful data on Tuesday at WMSA phone call
Basak Coruh
01:32:52
UWMC-Montlake’s first (and only) extubation was on day 17
mark
01:33:13
At least one report of a patient extubated after 3 weeks on vent
Dr. Melissa Lee, Evergreen Health
01:33:41
We had an 84yo F that was successfully extubated after 10 days of ventilation and now on 1-2lpm nasal cannula
Dr. Melissa Lee, Evergreen Health
01:34:01
I am not sure so much age, but co-morbid and WEAKNESS…
mark
01:34:02
Counted that one
Sharukh Lokhandwala
01:35:35
spoke with friends at MGH--they have had a few true myocarditis patients thus far. Not sure about UW any myocarditis/cardiomyopathy yet
Sudhakar Pipavath
01:36:18
is this due to two different strains? Does anyone believe that?
stephaniecooper
01:37:38
Wuhan Cardiologist on teleconference stated the patients they echo’d with severe disease often had mildly reduced EF, ~ 45%. not published.
Basak Coruh
01:38:30
Very hard to distinguish myocarditis from sepsis-induced cardiomyopathy or acute cor pulmonale
jainy
01:38:44
We have not had any true confirmed myocarditis cases yet. Stephanie can correct me if I am wrong.
stephaniecooper
01:38:51
couple of cases in UW system called ‘takostubos’ with ST elev, reduced EF, clean cors, elev trop. ? whether this is takostubos or could be myocarditis?
Jairo Santanilla
01:39:50
could the compliance issue be due to the early intubation?
Tony Raubitschek
01:40:01
The paper out of Evergreen described cardiomyopathy in 7/21 patients,
Dr. Melissa Lee, Evergreen Health
01:40:28
one of those 7 had classic myocarditis signs and pathology was different
stephaniecooper
01:41:09
one published case report of MRI evidence of myocarditis, otherwise I agree it is hard to distinguish. There are precovid published ‘criteria’ for myocarditis we should try to use
Dr. Melissa Lee, Evergreen Health
01:42:25
Any thoughts on the prolonged effect of qtc with both Azithro and HCQ?
benditt
01:42:31
Why are we using non-evidence based practice expensive medications that are needed for other patients ?
mark
01:42:33
You stop shedding virus when your heart stops
Sharukh Lokhandwala
01:42:42
Lots of issues with prolonged Qtc
T Dardas
01:43:46
I agree with Josh B- we should stop this before causing harm.
benditt
01:44:01
Primum non Nocere
Seth
01:44:27
Amen
Hassan
01:44:44
OR ideally, we should start enrolling in studies for hydroxychloroquine, and get answers to the questions
Nick Johnson
01:44:46
PETAL-sponsored hydroxychloroquine RCT to start within next 1-2 weeks; we hope to enroll at multiple UW sites and understand both safety profile and efficacy.
stephaniecooper
01:44:54
we have a QT monitoring protocol - EP does not think they have seen it with HCQ only ,but not enough patients adequately monitored yet. We are monitoring everyone now so should know more in 1-2 weeks? HCQ + azithro fewer pts.
mark
01:45:15
When will we learn that surrogate markers in critical care that do not predict outcome. High tidal volumes improve oxygenation
Chi Hung
01:46:42
Any evidence or ongoing clinical trials on the use of toci (or any biologics) in COVID or any respiratory viral infections leading to ARDS? Cost??
Amy Morris
01:46:57
Chi just beat me to it- Any investigations into anakinra ongoing? Less expensive than toci, and theoretically IL-1 a good target to quell cytokine storm too
Sharukh Lokhandwala
01:47:40
Gilead is doing an RCT of toci
Sharukh Lokhandwala
01:47:44
I believe
stephaniecooper
01:48:06
Anyone from ID on here? I know they’ve talked about this, don’t know what they are thinking/planning
Basak Coruh
01:48:46
This is from 3/27, so probably already outdated:
Basak Coruh
01:49:05
https://pbs.twimg.com/media/EUNYmD6X0AIjxdQ?format=jpg&name=4096x4096
mark
01:49:21
Yes, the use of toci is being re-evaluated at UW. We are not part of the trial.
Mark Sullivan
01:51:49
Toci is getting a lot of traction at Swedish, but seems to be the bandwagon drug at this time. Good critical care is confounded by the flavor of the week drug due to poor study methods
sam
01:52:08
amen
benditt
01:52:39
The concept of equipoise seems to have been lost.
mark
01:53:21
As Dave Pierson would say: Don’t just do something, stand there
paula carvalho
01:53:26
Was there any evidence of macro or microthrombi in the pulmonary vasculature?
Jairo Santanilla
01:53:57
any DAH?
JM Lacy
01:54:22
Two cases from Everett had large clot burden
stephaniecooper
01:54:46
Haha, that is my very favorite saying. Did not know I was quoting someone. However, this seems a little harsh for our ID colleagues who are conferring a lot and equipoise is part of their conversation.
Sudhakar Pipavath
01:55:34
insitu thrombosis or dvt leading to PEs?
JM Lacy
01:56:16
PA and right atrium (one case got TPA, still had large clot) didn't look in legs for safety reasons
JM Lacy
01:56:43
Clots looked emboli
JM Lacy
01:56:50
embolic*
GenOncTxpPulm Fellow
01:56:55
The potential "prothrombotic" nature of COVID seems to be emerging as the new emerging finding / concern in critically ill patients
mark
01:57:28
UW ID has done tremendous work in this regard and the document they have produced is a great resource. I really appreciate how willing they are to engage and reassess along the way. I just wish we were enrolled in a trial for anything we are giving these patients
stephaniecooper
01:57:34
Chinese docs have talked about this from the beginning, an actually recommended on one webinar anticoagulation everyone critically ill!
Sam Rayner
01:58:05
Yes, also curious about presence of pulmonary microthrombi. There was a paper suggesting TPA for ARDS in COVID ARDS
Patrick Weis
01:58:29
H1N1 had evidence for microthrombi too
Patrick Weis
01:58:33
https://www.atsjournals.org/doi/full/10.1164/rccm.200909-1420OC
Sudhakar Pipavath
01:59:13
is lymphopenia unique to COVID or is it seen in most viral LRTIs?
Timothy Clark
02:00:17
don't forget about Xigris use in the early sepsis treatment- later proven not valuable
Wendy
02:00:44
Lymphopenia not seen in most viral LRTIs per hematology talk I saw last week.
Tom Martin
02:01:09
Which cells in the lungs had the viral particles by EM?
Mohammed Nayeemuddin
02:01:10
early onset of severity of this lymphopenia seems to be unique to covid. You can see severe lymphopenia late in ARDS but its not a guarantee
pratikv
02:01:14
did the decedents with autopsy performed have +virus in the nasopharynx?
Kathryn (Kailey) Bolles
02:01:18
other viral infections have lymphopenia (though not necessarily traditional viral URIs) but it can help make the constellation of symptoms/labs for coronavirus infxn and maaaaaybe is prognostic https://www.medrxiv.org/content/10.1101/2020.03.01.20029074v1?
pratikv
02:01:25
meaning at the time of death
Patrick Weis
02:01:30
You would think that if DAD common path, that we would see worse compliance
JM Lacy
02:01:32
EM positive cells where pneumocytes
stephaniecooper
02:02:13
Thanks Pathology! this is hugely helpful, we are going to rely on our pathologist findings for better understanding
Basak Coruh
02:02:41
Yes, thank you! Just to clarify, we are now doing autopsies at UW for patients with COVID-19? We were not previously
Jerry
02:02:46
COVID affects hemoglobin and heme metabolism. Relevance: in terms of oxygen carrying capacity? https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173
JM Lacy
02:02:48
Autopsy decedents positive antemortem where NP positive; autopsy cases were a combination of primary bronchus swabs and NP
Sharukh Lokhandwala
02:04:12
that path discussion was fantastic, Thank you very much!
Desiree Marshall
02:04:15
I am sorry. I forgot to mention micro thrombi. So far, we did not identified definite micro thrombi in vessels, including lungs and kidneys. No evidence of DAH. Would have to review medical records to see which patients had clinical concern for or dx of DVT.
Hugo Carmona
02:06:02
Thank you Dr. Marshall! interesting to hear no micro thrombi given the discussion about “uniformly” anticoagulating some critically ill patients
Michael G Holmes
02:09:09
I will add here that the Fabius sucks for high PEEP/high Mv applications. I called for a Revel during most of my lung transplants at UW. The newer Apollo (available at UW) and Perseus anesthesia machines (not at UW) are better.
Sudhakar Pipavath
02:10:23
is shortage of ventilators leading to increased mortality? or is it ARDS severity?
Sharukh Lokhandwala
02:10:37
we don't have a shortage yet
Alex Bryant
02:10:37
One hopes many of these patients may not need very high PEEP/Mv if the early shunt/compliance data are born out.
ylinne
02:10:44
Anesthesia machines seem interesting for use in settings where ICU care might need to be provided in a non-ICU area, given capability for additional monitoring in addition to ventilation.
thomaskeller
02:11:14
One issue with anesthesia machines is ease of mobility
nona
02:11:24
Will the slides be available for distribution? It would be helpful.
Desiree Marshall
02:11:28
FYI. We are currently getting permission and writing our protocols to use an isolation suite in Health Sciences to be able to perform limited, in-situ autopsies (no brain) at UW. We are at least a week out. I will get communication out about that. At this time, do not offer autopsy as we cannot guarantee. Even when we get space, will only be able to do limited cases. We will be asking our clinicians to bring potential cases to me. We may also have point people in cardiology and MICU to help with prioritizing autopsies. We are also continuing to work with King County and Snohomish MEs to address autopsy needs.
stephaniecooper
02:11:36
whole talk will come on youtube
Michael G Holmes
02:11:47
They'll get the job done, just need to be careful pairing specific anesthesia machine types to disease severity.
Michael G Holmes
02:12:24
Added bonus, if we run out of Propofol/midaz/ketamine/dexmed, low dose iso will get the job done!
Sharukh Lokhandwala
02:12:46
nice side bonus
Alex Bryant
02:12:55
Yeah, adding parameter limits of the Tier 2/3/4 machines would be helpful for ICU providers
barnesc
02:13:01
Agree with Holmes- Most patients that are critically ill and have poor oxygenation AND poor compliance, it is standard at HMC to continue ventilation via ICU ventilators.
thomaskeller
02:14:05
Would we expect patients to use only one “ventilator” during their hospitalization once assigned?
Alex Bryant
02:14:06
Of course, this is all contingency planning and how to match nonstandard machines to patients in surge scenario
Katie Heller
02:14:15
agree with Mike about the Apollo machines, though at least at UW the hope is that the anesthesia machines would start for non-ARDS patients
vhapugedelmj
02:17:36
How difficult would it be to retrofit filtration to the circuit?
Timothy Clark
02:18:14
please address the masked NIV use in COVID briefly at the end. I'm finding variable enthusiasm and caution
Molly Billings
02:20:10
The bilevel S/T devices only have max pressure of 30cm so I wonder if they would be able ot deliver adequate Vt and PEEP (which would be EPAP). Seems tricky.
james
02:20:47
could you do inverse ratio w/ NIV?
vhapugedelmj
02:21:04
Or in "recovery" period/weaning
Jim deMaine
02:22:14
Any interest in 2 or 4 patients on a single vent?
Matt Wemple
02:22:28
This is such great work Josh!
Michael J Bishop
02:23:39
The American Society of Anesthesiologists has prepared advisories on how to use anesthesia vents for ICU patients. Also, just establishing 24/7 phone consultation service for anesthesiologists to assist in this. Probably less critical in major centers but may be especially useful in smaller hospitals that have lots of OR and few ICU vents.
Timothy Clark
02:23:53
doubling patients has been strongly discouraged
Vanessa
02:24:06
multiple societies have come together to recommend against split ventilators. you can potentially hyperventilate one patient and hypoventilate the other, possibly hastening the demise of all patients involved
Hugo Carmona
02:25:18
MJB, that 24/7 access line sounds amazing
Andy Luks
02:25:24
There is a protocol that was put out by the Greater NY Hospital Association on how to do split ventilation if necessary. Unable to load it here. I’ll try to find a link
Vanessa
02:26:13
hooking up the connections is the easy part. How you monitor patients is the crucial part.
benditt
02:26:35
Slides will be available.
benditt
02:28:22
I agree. No splitting. The equation of motion tells that ventilation to two different patients will be very different and can vary widely over time.
Andy Luks
02:28:54
This is the NY Hospital Association Protocol. Very well thought out and appropriately qualified as a last resort: file:///Users/andrewluks/Downloads/Ventilator-Sharing-Protocol-Dual-Patient-Ventilation-with-a-Single-Mechanical-Ventilator-for-Use-during-Critical-Ventilator-Shortages.pdf
benditt
02:29:26
I am recommending that CPAP or BPAP use would have to be done in full PPE. The aerosol potential for those devices is not well known but is likely variable and potentially high.
ylinne
02:29:42
even in non-covid patients?
ylinne
02:30:34
if we're assuming that we would try to reserve those for non-covid respiratory failure
Dan Doan
02:30:41
Is there a difference in sensitivity between the Rapid assays and the standard NP swab?
benditt
02:30:47
The NY Hospital Association document is very good. Unfortunately, the same authors who developed that put together an AARC statement, available at their website that suggests not splitting ventilators.
Sam Rayner
02:30:58
Could someone comment on how we are sending ET aspirates? CDC/WHO/SCCM All recommend moving to ET aspirate when you have a negative NP swab in an intubated patient with clinical suspicion for COVID, but I have had a hard time enacting this within our system. Now that sputum is approved do we send this as sputum?
benditt
02:31:51
COVID test negative patients do not need to be isolated for CPAP/BiPAP. I think they should be tested and found to be negative before stopping PPE.
james
02:32:07
@Sam - we have sent both ETA and BAL samples at HMC
Andy Luks
02:32:11
Here’s a working link on the split ventilator protocol: https://www.gnyha.org/news/working-protocol-for-supporting-two-patients-with-a-single-ventilator/
Timothy Clark
02:32:32
In non-COVID pts, I would assume usual practice. For COVID, I favor avoiding NIV due to aerosolization concerns
Sam Rayner
02:32:36
Thanks, James! At UW this had often taken many calls to lab medicine. Maybe now it will be easier. Would love to see this standardized in our protocols (intubated with suspicion for COVID should move to ET aspirate if negative NP)
Alex Bryant
02:32:40
FYI - there is a lot of chatter in EM/EMCrit channels about using HFNC or NIV in lieu of early intubation, despite past ARDS experience. This may confuse early management and PPE use, especially if centers lack a standard approach.
Jim deMaine
02:32:43
when are we going to have enough tests to do surveilance in nursing home?
Matt Hallman
02:32:48
How long does it take to clean and reenter into service a ventilator when changing patients?
Anna Condino
02:32:50
Unless we get <30 min reliable rapid testing, we won't know Covid status when patients present to the ED in respiratory distress/failure. Ideas for modifying existing NIV interfaces to make them non or less aerosolizing so we can treat, temporize, or pre-oxygenate these patients with unknown Covid status? And get RT buy in to come help us?
GenOncTxpPulm Fellow
02:32:57
The <72h since last negative COVID testing is leading to a marked increase in repeated testing for many inpatients (and outpatients) requiring procedures
vhapugedelmj
02:33:08
Does PCR cycle time provide any clinically relevant insight?
Kathryn (Kailey) Bolles
02:33:11
how are you defining non-COVID patients for stopping PPE on NIPPV? single or dual test for R/O given difficulties with sensitivity?
GenOncTxpPulm Fellow
02:33:13
COncern for false negatives is alarming
bhatraju
02:33:14
Is there any data to tell the false negative rates for our current diagnostic test?
Michael J Bishop
02:33:41
Here is link to Am Soc Anesthesiologists info on using OR vents for ICU cases https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information/caesar
Sudhakar Pipavath
02:33:45
what is the sensitivity and specificity of this test? Does a negative test mean true negative.
Kevin Duan
02:33:52
any timeline on when serologies available?
Molly Billings
02:34:47
Would love to know when/if we can test for COVID exposure in HCW and if this will reliable way to mitigate risks
William A. Altemeier
02:34:57
Acknowledging that the data did not indicate what the sensitivity of NP swabs are, should we really be basing use of airborne precautions versus droplet precautions during bronchoscopy on one negative test?
Patrick C Mathias
02:34:58
Analytical sensitivity is 95-98% across all of our platforms - note that that measures concordance with known positive samples across platforms.
Michael G Holmes
02:35:06
Re: NIV devices: Duel limb CPAP circuits with a closed mask is one option (usually would have to use a duel limb ICU vent since we don't have NPPV specific circuits). I've also seen pictures of HEPA filters Macgyvered onto NPPV exhalation ports
Kathy Ramos
02:35:12
When determining “false negative” what is our gold standard? Clinical suspicion of COVID-19 with a negative test leads to false senses of security in my opinion.
Dan Doan
02:35:41
Is the new rapid test similar in performance to the standard nasopharyngeal swabs?
Patrick C Mathias
02:35:50
Clinical sensitivity is more challenging because many of the studies do not have a consistent definition of a COVID-19 case.
Monica Campo
02:35:56
Is the UW health care worker data available?
Patrick C Mathias
02:36:41
The new rapid tests is slightly less sensitive than our lab developed test but comparable to the other automated platforms.
Alex Bryant
02:36:41
@Monica, see the update email yesterday suggesting HCW rates are below community test positivity rate
Kathryn (Kailey) Bolles
02:36:43
yes, have seen estimates of single NP swab sensitivity as low as 50% but unclear what "gold standard" is so difficult to interpret
iPhone
02:37:49
hoping to have some data on clinical sensitivity of UW testing to share soon....maybe sighing the next week
Patrick C Mathias
02:37:51
Anesthesiology is doing an analysis of patients who are tested more than once. What I have heard is that the rate of positive after an initial negative is very low. But I am not sure that that analysis is complete yet.
Cliff S
02:39:03
1 or 2 patients in-house that were initially negative then positive on retest (HMC)
Sam Rayner
02:39:13
For SARS1 the sensitivity for NP was around 70% based on later seroconversion.
Kathy Ramos
02:39:24
Agree with Kevin Duan’s question above - any idea on timing of serology testing?
Sam Rayner
02:39:50
Sensitivity for NP was 50% in china when using CT as a gold standard (which is problematic)
Patrick C Mathias
02:39:54
We are actively working on bringing on serology testing. No ETA yet but this is a big push for Lab Medicine at the moment.
Sam Rayner
02:40:33
For this reason all the guidelines (CDC/WHO/SCCM) recommend using a lower sputum sample in an intubated patient BEFORE taking off precautions if you have clinical concern for COVID (with ET aspirate being preferred due to risks of BAL and mini-BAL which require breaking circuit).
paula carvalho
02:43:00
Regarding nasopharyngeal swabbing: We have a high rate of sneezing and coughing with the swabbing procedure. Some of these are quite violent. Why is NP swabbing considered to not be an aerosol-generating procedure?
GenOncTxpPulm Fellow
02:43:24
how about taking MRSA and VRE off contact precautions?
Kathy Ramos
02:43:42
If patient is coughing, are they generating aerosols?
barnesc
02:43:59
https://www.nature.com/articles/d41586-020-00974-w
Alex Bryant
02:44:00
MRSA/VRE de-escalation is reportedly coming soon
Kathy Ramos
02:44:17
(Most are coughing, I believe)
Basak Coruh
02:44:25
Fantastic news!
Alex Bryant
02:44:27
droplet != aerosol
Timothy Clark
02:44:34
in Boulder, we have already taken remote MRSA pts off precautions
Alex Bryant
02:44:59
but I wonder if anyone's measured aersol vs droplet amounts from actual humans coughing/sneezing
barnesc
02:45:00
It seems like there is growing uncertainty about whether COVID-19 should be droplet vs aersol precautions, do we know if this is being discussed within our institution?
Kathy Ramos
02:45:00
Yes - I know, but there has been talk that cough generates droplets that linger in the air for up to 3 hours (in an aerosol fashion)
Matt Wemple
02:45:01
VA has done this for floor patients but not ICU patients
chris
02:45:04
Coughing likely more aerosolizing than high flow/NIV...Abrupt high flow rates expelling lower respiratory secretions...
Matt Hallman
02:45:21
I understand taking MRSA/VRE patients off precautions, but I don’t understand why we would stop screening for these colonizations…don’t we still want to know if they are MRSA or VRE+?
jainy
02:45:46
Is there going to be a system for accessing N95 or PAPR for TB r/o? Had difficulty with this today
Mike Holmes
02:46:12
Seems like MRSA positivity would be good to know for those with covid that develop superinfections
Alex Bryant
02:46:49
Yea, I didn't find anything on a search earlier this week for naturally-generated droplets vs aerosol particles. Only found data on viral transmission vs PPE use for flu.
ylinne
02:47:22
agree with mike - helpful in general for empiric antibiosis
Dr. Melissa Lee, Evergreen Health
02:47:37
is there a definition to type of UV light?
Anne Lipke
02:48:09
concern about degradation of efficacy on N95 after exposure to UV light?
Timothy Clark
02:48:10
we are currently using UV decontamination of N95s
Timothy Clark
02:49:02
anybody using double masks? ie surgical over n95?
Mike Holmes
02:49:22
UV works, but is dose dependent and causes some degradation. Dry heat (70 degrees for 30 mins) probably causes least degradation from what I understand
Dr. Melissa Lee, Evergreen Health
02:49:22
Share Anne Lipke’s question regarding integrity of N95 with UV light
Mike Holmes
02:49:31
At Swedish, we're using surgical masks over extended use N95s
stephaniecooper
02:49:32
Critical care medicine/Chest rings the bell again with an incredibly informative multidisciplinary presentation. Thanks Hugo, Andy et al
ylinne
02:50:11
https://www.ncbi.nlm.nih.gov/pubmed/25806411
Hugo Carmona
02:50:12
Thanks @stephaniecooper!
ylinne
02:50:59
N95 reuse cycles depends on respirator and UV dose
Hugo Carmona
02:51:23
@ylinne, I’m so glad someone has already done that research
Seth
02:52:51
Agree ylinne. We will likely be limiting to 5 cycles, less if there is evidence of degredation (eg fit, loss of elasticity, nose piece, etc)
Jairo Santanilla
02:52:59
it is my understanding that the algorithms should be publicly discussed and transparent — correct?
vhapugedelmj
02:53:23
How is NY allocating care/resources?
Seth
02:53:26
here’s a protocol from nebraksa for those curious: https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf
Timothy Clark
02:54:22
Colorado Crisis Standards of Care were easy to find on the health department website. Likely true for Washington as well. Quite reasonable decision tree
Patrick Weis
02:54:50
Dr Tonelli, Does the argument of non-beneficence for CPR when patient has ARDS (and worsening), or how should institutions address this?
Kathryn (Kailey) Bolles
02:55:09
Stanford also has a nice review on mask decontamination https://stanfordmedicine.app.box.com/v/covid19-PPE-1-2
Mark Tonelli
02:58:56
Visit the Northwest Healthcare Response Network for updated versions of Triage Guidelines and algorithms as they become available. NYC has not yet declared crisis standards of care and are still trying to provide ICU level care to all those in need.
Vicki Sakata
02:59:17
Hi Everyone. Thank you Mark for your great overview. This is Vicki Sakata, MD Sr. Medical Advisor with NWHRN. All the Scarce Resource Material is available on our website where we will be posting updates. The current link is for the algorithms that are being currently updated. They were developed as general guidelines that always need updating given the situation at hand. I am hosting evening meetings Tuesday and Thursday 7-8 pm. If you are interested in attending please email me at: vicki.sakata@nwhrn.org. Thanks to all for all your work during this incredibly stressful time. It's truly inspiring how many people are coming together to figure out how best to care for our patients. vs
Vicki Sakata
03:00:29
here is the link for the current CSC materials but they will be UPDATED, we are waiting for the state to review: https://nwhrn.org/wp-content/uploads/2020/03/Scarce_Resource_Management_and_Crisis_Standards_of_Care_Overview_and_Materials-2020-3-16.pdf
Vicki Sakata
03:02:15
apologies for the long notes! the evening meetings are specifically about Crisis Standards of Care. Tonight we will be discussing Palliative Care.
Hugo Carmona
03:03:47
@vicki Sakata thanks very much for sharing this!
Dr. Melissa Lee, Evergreen Health
03:05:13
These language sentences are helpful. Are you working on some if we need to approach families for resource limitations?
Jairo Santanilla
03:05:34
Have you seen inappropriate DNRs in places with high C19 numbers? i.e. no intubation in 60 yo with no comorbidities
Hugo Carmona
03:05:53
@Dr. Melissa Lee, https://www.vitaltalk.org/guides/covid-19-communication-skills/
Basak Coruh
03:05:55
@Melissa: VitalTalk has great examples
pratikv
03:06:16
We have not seen inappropriate DNR's in the UW Medicine System. Randy Curtis
Cliff S
03:06:32
@jairo i saw an attempt at DNR for a 31yo crossfit athlete
Cliff S
03:07:23
that was an isolated specific interaction though...
Jairo Santanilla
03:07:27
i am assuming the 31 yo was given a shot?
Cliff S
03:07:42
shes extubated!
Jairo Santanilla
03:08:24
:)
Erin Kross
03:08:43
@Melissa Lee -- The vital talk reference has a whole section around crisis capacity communication -- super helpful!
Dr. Melissa Lee, Evergreen Health
03:08:55
thanks Erin!
Basak Coruh
03:09:08
That may have been appropriate if patient was critically ill and on maximal medical therapy…CPR may not be medically appropriate if cardiac arrest occurs on maximal support. That can be reassessed with improvement.
Kathy Ramos
03:09:12
I think it’s important to understand prognosis when having these conversations about DNR status. I heard that there was a hospital in FL planning to use FEV1 <30% for CF patients as an exclusion criterion for ICU care, even though median survival is ~6.5 years or longer and there are improving ICU outcomes for patients with CF, especially with Trikafta. Everything is a balance when resources are limited, but having an accurate understanding of prognosis is important.
Erin Kross
03:09:43
I agree with Randy's comment above -- I also have not seen inappropriate DNR orders at Harborview.
Erin Kross
03:10:38
@ Kathy Ramos -- I completely agree. Without some knowledge and understanding of prognosis, it's challenging to balance these with patient values and make recommendations.
Kathy Ramos
03:10:49
Thanks, Erin!
thomaskeller
03:11:37
Tonelli, or someone, could you comment on how the ACLU lawsuit preventing decisions on resource utilization to be based on age/comorbidity has influenced Washington State’s crisis plan?
Shewit Giovanni
03:12:00
is that recent tom?
thomaskeller
03:12:14
Happened a couple of days ago
terri
03:15:02
Cachexin (aka TNF-a) leads to fever and cachexia-- suspect we are seeing lots of muscle breakdown. Might be some of the elevated CK and myoglobin reported, too
Sharukh Lokhandwala
03:15:05
the pushups are impressive
Molly Billings
03:15:37
Are you using steroids at all? Or is it all critical illness/ myopathy from virus?
Anne Lipke
03:16:05
no steroids here with two exceptions.
GenOncTxpPulm Fellow
03:16:17
proning hypoxemic patients before they have required intubation has been popping up in coversations with some colleagues at other institutions
Sharukh Lokhandwala
03:16:36
have not used steroids here with exception to one who had clear evidence of concomitant COPD exacerbation
Anne Lipke
03:16:41
the weakness may be from the inflammation as Terri pointed out and the duration of ventilation
Sharukh Lokhandwala
03:17:18
JT without a beard is like boyband level
Cliff S
03:17:33
unclear prevelance of covid encephalopathy which has been reported as well
Mark Tonelli
03:17:55
Anne Lipke sent the first text message out early in this outbreak. The community of CCM clinicians in this community is impressive
6119
03:18:52
Nunez@ ValleyMC - Anyone have a protocol for proning nonintubated patients?
Kathryn (Kailey) Bolles
03:19:30
@Kristen Rogers is working on a protocol
Alex Bryant
03:19:40
https://www.ncbi.nlm.nih.gov/pubmed/26271685
Kathryn (Kailey) Bolles
03:19:47
but seems very experimental at this point
Katie Heller
03:20:37
thoughts on “early intubation” vs waiting for more severe respiratory failure?
james
03:20:37
i get carded all the time now!
Sam R Sharar
03:20:42
Recent warnings of impending propofol shortage should be factored into ICU sedation plans, with alternative meds (e.g., dex, midday)
terri
03:21:21
There is an RCT of non-intubated prone positioning (COVID-PRONE) starting soon
Sam R Sharar
03:21:27
midaz
Aaron Joffe
03:21:32
Propofol is now on national shortage, so that is a consideration when considering what the “best practice” for sedation and analgesia. Very well may need to cycle through what we do depending on medication usage.
barnesc
03:21:52
@Sharar- I'm hearing that Dexmed will be on shortage soon as well
bradyan
03:22:49
we had a prolonged encephalopathy case here at OHSU but can't comment on sedation usage
Katie Heller
03:22:59
we have several IV pumps outside the rooms, key is to put the extensions on each actual IV drip then plug in close to infusion site
Mohammed Nayeemuddin
03:23:13
In the spirit of community, just want to introduce myself. I'm Mohammed "Zeeshan" Nayeemuddin, one of the PCCM attendings at Highline medical center in Burien, WA (2 miles from SeaTac airport). Our group has been listening in on these zoom meetings regularly and we're loving all of the information and support you guys provide. Keep up the strong work and don't hesitate to reach out if you need anything. mohammednayeemuddin@chifranciscan.org
Timothy Clark
03:23:26
I have been a fan of minimal fentanyl for a long time, in this absence of clear analgesic indications
james
03:23:40
Welcome Mohammed! We’re all in this together!
barnesc
03:24:17
Gotta remember propylene glycol toxicity if we need to transition to Lorazepam for sedation.
Sam R Sharar
03:25:39
If you haven’t seen yesterday’s NEJM Perspective on Seattle HCWs “harnessing humanity”, it’s a must read … https://www.nejm.org/doi/full/10.1056/NEJMp2007466
Timothy Clark
03:25:46
say the name of that visitation program again..
Sharukh Lokhandwala
03:25:56
blue jeans
Ashley
03:26:08
I may be one of the only pediatric critical care providers here but we may be a good resource for these sedation questions as they arise given our standard sedation is generally fentanyl and midaz infusions +/- precedex if needed. The propylene glycol toxicity also came to mind for high dose lorazepam.
Sharukh Lokhandwala
03:26:09
like levis
Kathy Ramos
03:26:28
It’s a video conferencing service like Zoom. We use BlueJeans routinely with the CF Foundation
Engi
03:26:41
Becton & Dickinson (BD) have just announced that they've developed Rapid IgM and IgG antibody testing for COVID-19 on plasma/serum/blood. Will our lab start offering this test?
Bernice G
03:26:42
very similar to zoom
David Carlbom
03:26:44
Zoom has PHI version, and we have set up 24h/day meetings that recur daily for each room: one for family, one for medical teams. Can also do this for ICU teams so some team members can round remotely.
HMC Pulmonary (Leila)
03:26:46
uw.phi.zoom is similar and HIPAA compliant
Patrick Weis
03:27:10
is anyone doing PCR after 2 or 3 weeks to see if still shedding?
Hugo Carmona
03:27:33
@Engi, patrick earlier mentioned it’s a priority to have access to IgM/IgG testing, but no clear timeline
Hugo Carmona
03:27:44
priority for the lab*
GenOncTxpPulm Fellow
03:27:46
is the weakness concerrent with elevated CK?
Mary King
03:27:59
Re: Precedex
Matt Wemple
03:28:16
Any ketamine usage?
Mohammed Nayeemuddin
03:28:27
@patrick we have had positive swabs in 3 week plus patients even post extubation
Dr. Melissa Lee, Evergreen Health
03:28:34
we are starting to build ketamine protocols for sedation
Dr. Melissa Lee, Evergreen Health
03:28:43
in anticipation of shortages of our usual drugs
Katie Heller
03:28:58
working on getting low dose ketamine up and running at UWMC as an adjunct as well
Nick Johnson
03:29:31
We already have a ketamine protocol at Harborview, and had a discussion with our pharmacy team about using it more.
Bernice G
03:29:37
what about issues around false negative testing
Timothy Clark
03:30:07
is the UW ketamine protocol public?
Matt Wemple
03:30:08
yes
Patrick C Mathias
03:30:12
We are evaluating at least 3 different serology platforms in UW Lab Medicine. Not sure if BD is one of them but one important point is that the manufacturer provide test needs to be compatible with our instruments to be able to do it at scale.
Jairo Santanilla
03:30:15
we initially did not extubate folks with use of NPPV or HFNC due to concerns of viral spread… We are now going back to basics of what we know — NPPV and HFNC with descent success.
barnesc
03:30:53
Caveat to remember with Ketamine for sedation is that is a known myocardial depressant, further emphasizing our vigilance for evaluating for cardiac involvement with COVID-19
Anna Condino
03:31:29
Intubation box is a difficult interface. There has been talk of clear plastic/ponchos over the face in the EM community for intubation. Using glidescope, obviously.
Mary King
03:31:43
Re: Precedex withdrawal, in PICUs we use a lot more Precedex for long duration as we rarely use Propofol in children. We do sometimes encounter severe tachycardia, hypertension, agitation with rapid withdrawal. To avoid, we wean precedex slowly if was on for long duration. On occasion we transition to Clonidine to avoid symptoms
james
03:31:54
We love Melissa’s custom artwork!!