Acute COVID, What We're Seeing

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Doctors in the United States on Sunday called for the loss of sense of smell and taste to be added to the "list of screening tools" for Covid-19.

"Anosmia, in particular, has been seen in patients ultimately testing positive for the coronavirus with no other symptoms,"

https://www.cnn.com/2020/03/23/health/coronavirus-symptoms-smell-intl/index.html

3 hours ago, toomuchbaloney said:

Well worth a listen. 

Thank you, ToMuchBalloney

On 3/20/2020 at 6:40 AM, AJPV said:

How to share 1 vent with 2 or 4 patients:

 

The obvious problem, which isn't addressed in the limitations section of the study, is patient-ventilator dyssynchrony.   While the experiment worked fine on 4 lung simulators, which are comparable to 4 brain-dead patients.  But COVID patients in particular tend to over-breathe the vent even with liberal sedation administration, so there's no way a single ventilator could appropriately ventilate 4 different patients who are initiating their breathes at different times.  Paralytics would help with that, but there's already real concern about how our supply of paralytics will hold up, and these patient require long term ventilation, too long to safely give paralytics continuously.

Bonus points for creativity and Medical MacGuyvering, but I don't see this being particularly effective.

9 hours ago, DesertSky said:

MunoRN - Thanks for sharing your findings thus far.  I had read similar information coming out of Italy regarding patients having severe cardiac issues with low EF's resulting in cardiac arrest after some of the COVID-19 patients started to improve.  In Italy, I know some hospitals are not performing codes on these patients d/t there being nothing more than can really be done.  Has this been discussed in your institution?

 

We will code a non-intubated patient who would potentially benefit from going on a vent, but once their on a vent and on hemodynamic support they are made a medically futile DNR.

1 hour ago, MunoRN said:

The obvious problem, which isn't addressed in the limitations section of the study, is patient-ventilator dyssynchrony.   While the experiment worked fine on 4 lung simulators, which are comparable to 4 brain-dead patients.  But COVID patients in particular tend to over-breathe the vent even with liberal sedation administration, so there's no way a single ventilator could appropriately ventilate 4 different patients who are initiating their breathes at different times.  Paralytics would help with that, but there's already real concern about how our supply of paralytics will hold up, and these patient require long term ventilation, too long to safely give paralytics continuously.

Bonus points for creativity and Medical MacGuyvering, but I don't see this being particularly effective.

That was my precise concern (along with the issue of multiple patients with an upper respiratory virus breathing the same air...) Also, it seems like it could cause some major issues if one of the patients suddenly begin to require a very different mode/amount of support. Perhaps it’s different in adults, but I peds, different patients can require vastly different settings, and their setting requirements can change fairly rapidly. Two patients who start out the shift on the same settings may end up with very different ones. 

Edited Mar 24 by adventure_rn

8 hours ago, MunoRN said:

We will code a non-intubated patient who would potentially benefit from going on a vent, but once their on a vent and on hemodynamic support they are made a medically futile DNR.

Thank you for your thorough response.  I should have been more clear in my initial question, but you addressed what I was asking - I was referring to a "no code" in the case that the patient has already been intubated.

It was also interesting to hear thus far, COVID patients on mechanical ventilation have not been given paralytics in your practice.  I was wondering about this as we often given our patients in severe ARDS (obviously not COVID patients) paralytics as a last ditch effort to help their respiratory status before considering ECMO.  Your right about possibly running the risk of running out of paralytics as many of these patients are taking a long time to recover and come of the vent (if they do recover).

How does one disinfect a ventilator so that the virus isn't spreading through the equipment ?, given this is a new virus (we haven't necessarily had enough time with trial and error)?

On 3/18/2020 at 7:41 PM, Cowboyardee said:

it's the lack of hospital staff trained in critical care that might wind up being the worst bottleneck as the number of cases surge and doctors and nurses themselves get sick. 

Yes. I agree.  We actually have a relatively small ICU, and we will need to train Med-Surg nurses in critical care in order to handle the situation. Nurses need to be trained in handling respiratory distress at least.

On 3/15/2020 at 11:47 PM, MunoRN said:

COVID-19 has been in my area long enough that we're getting an idea of how it plays out, curious what others are seeing.

The most surprising thing has been the duration of acute illness, I sort of figured it would be like other respiratory viruses just more severe, but with acute symptoms lasting up to 7 days or so.

We've seen timelines similar to what China was reporting; about 10 days from symptom onset to needing ICU care, then critically ill for weeks, the shortest recovery we've seen is 3 weeks of aggressive life support.  Time from symptoms onset to death has ranged from 2 to 8 weeks in China.  So it's not just the number of patients that will require vents and other equipment, it's the length of time they will need them for.

The first week or so on the vent is similar to a bad influenza; lots of vent support, maybe proning, maybe flolan, not typically requiring inotropes or vasopressors, then they seem to have turned the corner and are out of the woods.  

Then they crump, big time.  From nothing to max pressors and inotropes and an EF that drops from normal to 10-15% in as little as 12 hours.  Sudden onset renal and liver failure, with impressively severe liver failure in such a short amount of time.  

Deaths appear more cardiogenic than respiratory, lethal rhythms have varied the full gamut; VT, VF, PEA, and asystole.  

We've had enough ventilators so far, but what likely lies ahead will be the need to figure out a process for taking ventilators and other life support equipment away from patients less likely to survive to make them available to patients more likely to survive.  Things seem dicey now, but that's a whole 'nuther level of dicey.  

Are you seeing various ages too? I'm assuming you haven't had a patient there long enough to wean from a vent.

On 3/16/2020 at 4:05 AM, skydancer7 said:

Thank you.  Wondering how hospitals are staffing up for this.  It's about to blow up in my area, I am just waiting for the ads for crisis nurses needed but haven't seen anything yet.  I guess I will start contacting hospitals.  Don't want to get back into nursing long-term but feel the need to come out of grad school land to help out for a few months...

Look for travel nursing jobs in NYC if interested. They are there.

Found at ABC News:

New York to allow hospitals to treat two patients with one ventilator

https://abcnews.go.com/US/york-approves-ventilator-splitting-allowing-hospitals-treat-patients/story?id=69816167&cid=clicksource_4380645_6_three_posts_card_hed

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New York hospitals can now attempt to treat two coronavirus patients with a single ventilator, Gov. Andrew Cuomo announced on Thursday, a move that could help the state make better use of its scarce supply of lifesaving breathing machines as the outbreak continues to surge.

New York-Presbyterian Hospital has developed a split-ventilation protocol that has been shared with the New York State Department of Health, which quickly approved the practice..

...“Why such a demand? It is a respiratory illness for a large number of people. So they all need ventilators,” Cuomo said Thursday. “Non-COVID patients are normally on ventilators for three to four days. COVID patients are on ventilators for 11 to 21 days. You don't have the same turnaround.”...

 

2015: VENTILATOR ALLOCATION GUIDELINES - Health.NY.Gov

https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

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Protecting the health and well-being of New Yorkers is a core objective of the Department of Health. During flu season, we are reminded that pandemic influenza is a foreseeable threat, one that we cannot ignore. In light of this possibility, the Department is taking steps to prepare for a pandemic and to limit the loss of life and other negative consequences. An influenza pandemic would affect all New Yorkers, and we have a responsibility to plan now. Part of the planning process is to develop guidance on how to ethically allocate limited resources (I.e., ventilators) during a severe influenza pandemic while saving the most lives.

As part of our emergency preparedness efforts, the Department, together with the New York State Task Force on Life and the Law, is releasing the 2015 Ventilator Allocation Guidelines, which provide an ethical, clinical, and legal framework to assist health care providers and the general public in the event of a severe influenza pandemic. The first guidelines in 2007 focused on the allocation of ventilators for adults, and were among the first of their kind in the United States. The 2015 version is also groundbreaking in that it includes two new detailed clinical ventilator allocation protocols –one for pediatric patients and another for neonates. The first Guidelines were widely cited and followed by other states. We expect these revised Guidelines to have a similar effect.

.. In a severe public health emergency on the scale of the 1918 influenza pandemic, however, these ventilators would not be sufficient to meet the demand. Even if the vast number of ventilators needed were purchased, a sufficient number of trained staff would not be available to operate them. If the most severe forecast becomes a reality, New York State and the rest of the country will need to allocate ventilators.

I was unaware that NY state Dept. of Health had a ventilator allocation protocol as have not seen anything in PA as part of disaster prep I've been involved.  Appears that these guidelines are being implemented. Therefore, hospitals  would need  NY Dept of health approval for vent sharing.   Unable to find  this split-vent protocol on today's search -will keep an eye out.

Karen

On 3/24/2020 at 8:45 AM, DesertSky said:

Thank you for your thorough response.  I should have been more clear in my initial question, but you addressed what I was asking - I was referring to a "no code" in the case that the patient has already been intubated.

It was also interesting to hear thus far, COVID patients on mechanical ventilation have not been given paralytics in your practice.  I was wondering about this as we often given our patients in severe ARDS (obviously not COVID patients) paralytics as a last ditch effort to help their respiratory status before considering ECMO.  Your right about possibly running the risk of running out of paralytics as many of these patients are taking a long time to recover and come of the vent (if they do recover).

This is closely related to ARDS, but really the COVID symptoms are distinct from typical ARDS.  The most effective vent settings have been spontaneous modes which wouldn't work with paralytics.  But mainly, as paralytics are given for longer and longer periods of time (more than a few days) you get to where long-term or permanent neurologic damage becomes inevitable, particularly in the setting of renal or hepatic impairment, which is not unusual in these patients.  

1 hour ago, 2BS Nurse said:

Are you seeing various ages too? I'm assuming you haven't had a patient there long enough to wean from a vent.

Look for travel nursing jobs in NYC if interested. They are there.

We've weaned a few from vents, the shortest time on the vent I think has been just under 3 weeks.  I should warn this isn't necessarily a scientific observation, but the ones that seem to have improved the quickest have been those able to get Remdesivir.