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josh farkas πŸ’Š
intensivist😷 FOAMite🌊 pocus nerdπŸŽ› coffee & iphone addictβ˜•οΈ leader of the rebel allianceβš”οΈ writerβœ’οΈ resuscitationistπŸ’‰ feministπŸ‘©β€βš•οΈ aweful spellur😬 no COIπŸ’°
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josh farkas πŸ’Š 1h
Replying to @DarrellCaldero3
nothing too special. they’re in negative pressure rooms with N95 etc. we extubate to HFNC or CPAP (which is OK according to ANZICS guidelines).
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josh farkas πŸ’Š 2h
my preference is usually to use dexamethasone 10 mg daily. stop at some point based on CRP & clinical picture... dex auto-tapers itself off.
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josh farkas πŸ’Š 2h
Replying to @NinjaFarmD
nice selections!
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josh farkas πŸ’Š 2h
Replying to @PulmCrit
some patients with COVID seem to be unusually difficult to sedate (not sure why?), so other adjuncts like phenobarbital are likely to come into play as well. careful dosing is essential, because the half-life is long! (#6/6)
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josh farkas πŸ’Š 2h
Replying to @PulmCrit
as we run out of propofol, sedating atypical antipsychotics may become an important sedative (to reduce the dose of propofol needed). olanzapine may be ideal due to lack of QTc prolongation. minimizing propofol dose may also help avoid hypertriglyceridemia from HLH. (#5/6)
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josh farkas πŸ’Š 2h
Replying to @PulmCrit
for example, scheduled acetaminophen and pain-dose ketamine infusions can go a long way towards alleviating pain (thereby minimizing opioid requirements). ketamine also has anti-depressant and perhaps anti-IL6 effects. (nope, there's nothing that ketamine can't do.) (#4/6)
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josh farkas πŸ’Š 2h
Replying to @PulmCrit
the fundamental principle is multi-modal analgo-sedation. using *low* doses of *several* medications maximizes synergistic efficacy, while avoiding the toxicity of any specific agent (#3/6)
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josh farkas πŸ’Š 2h
Replying to @PulmCrit
if possible, achieving an awake & comfortable patient on the ventilator is enormously beneficial: - easier to extubate - can communicate, determine sources of pain - might help avoid lung-injurious tidal volumes - less delirium, faster rehab (2/6)
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josh farkas πŸ’Š 2h
new section on the mixology of analgo-sedation for intubated COVID patients. there are lots of approaches analgo-sedation, this is my favorite mix...(1/6) IBCC section:
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josh farkas πŸ’Š 6h
agree, aspirin seems like the most sane option here.
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josh farkas πŸ’Š 7h
Replying to @almoskow
depends on renal function, weight. usually we aren’t.
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josh farkas πŸ’Š 7h
all respiratpry support consists of either: 1) buying time without hurting the lung 2) buying time while hurting the lung
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josh farkas πŸ’Š 8h
Replying to @intubatesedate
not currently πŸ€·β€β™‚οΈ
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josh farkas πŸ’Š 9h
Replying to @OrenFriedman
πŸ™πŸ™ thanks so much!! let me know if anything needs revision... keeping it updated is a full time job...
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josh farkas πŸ’Š 11h
Replying to @HeartBo96691683
yes agree - potential steroid use is for patients with resp failure "ards" and cytokine storm.
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josh farkas πŸ’Š 11h
Replying to @leochacon
fantastic!! based on the numbers these patients would generally be expected to have very high mortality.
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josh farkas πŸ’Š 11h
the Italians seem to have a much better supply of toci than we do in US/canada.
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josh farkas πŸ’Š 11h
super cool. as a pressure-defined mode, this could theoretically work. let me know when the post is up.
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josh farkas πŸ’Š 11h
Replying to @JSchoolerMDPhD
please read the thread. that's what i said.
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josh farkas πŸ’Š 12h
Replying to @PulmCrit
yes, I know the evidence supporting this is very poor. this may seem desperate, and perhaps it's the wrong thing to do. it's intended merely as an attempt to throw a rope to these patients who are failing basic supportive therapy, pending the availability of better data (5/5)
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