I want to share my recent ICU experience in 75 y/o patient with combine influenza B + COVID 19 infection, required intubation for 6 days for ARDS now successfully extubated currently on room air for last 36 hours and doing well. She was required hydrocortisone stress dose for CIRCI(as she had hx of adrenaline insufficiency on po steroids at home before admission). On contrary to high mortality in COVID patient required vent, she did well despite of steroids use.
Congratulations on getting her extubated… it will be interesting to dig through the data at the end of this pandemic and see what our eventual success rates in getting pts extubated were… did earlier intubations effect the eventual status?
@trupesh_Chanpura and @julia.beatty: We are currently avoiding steroids since there were some studies that state that steroids can exacerbate virus (think it was in SARS) replication, unless as it was mentioned that there as adrenaline insufficiency or so on.
Kudos to your team @trupesh_Chanpura for the extubation!
Thanks @neilnf and @Jas_Singh. She did surprisingly very well and discharged from hospital last week. We are planning to analyze our hospital data in near future to learn what works better for COVID-19 patients. Evidence is changing everyday and we are trying to implement best approach in our ICU.
Is anyone using incentive spirometer aggression Covid 19 pts that are not intubated? Furthermore… if pts are running O2 sats in the low 90s … with supplemental O2…is anyone using proning in this situation ?
Jas Singh MD
Patient come to ICU with COVID at our institution are intubated on vent so less experience on incentive spirometry but I discussed with one of my physician(PulmCC) friend about proning awake COVID patient on supplemental oxygen helps a lot and might prevent or delay need for intubation. Hope this help to answer some of your question.
In our institution we are giving steroids at 0.5 mg- 1 mg/kg/day of prednisolone or equivalent in critically ill patients. What should be the ideal duration of steroids use?
We capped the duration to seven days in our critical care.
@Jas_Singh we are definitely proning on the floor. But if they have tachypnea or dyspnea with hypoxia then we empirically intubate.
Thank you Neil for your response… what we have noticed is everyone who is intubated with covid19 is in the middle of a cytokine storm… as a result … we are administrating an immunosuppressive… Tocilzumab… it’s still too early to see if this therapeutic is working. Additionally… we are aggressively probing for 16-20 hrs which is definitely improving our ABG results allowing us less fio2 support.
Published today in Critical Care Explorations: Rationale for Prolonged Corticosteroid Treatment in the Acute Respiratory Distress Syndrome Caused by Coronavirus Disease 2019
Thank you for sharing. Agree with inflammatory cytokine probably more harmful rather then risk of viral shedding.
The only indication of steroids in COVID19 patients is a stress dose if the patient is on prednisone 10mg per day Chronically
Much appreciated!! Just shared with my medical team and will hopefully extend our therapy
According to my little experience with COVID19 patient in our facility.
If the patient developed severe ARDS from COVID19 and Despite the lung protective MV, proning and fluid management the patient Oxygenation did not improve within 7 days, we start thinking about steroid use and ECMO. We started steroids on one patient on 1mg/kg on day 12 and he is improving now!! is it because of steroids or this is the course of the disease we don’t know.
The other situation is if the Pt is COVID19 positive and in septic shock on two maximum pressors we use steroids for the shock (shock does)
And if the Pt has Hx of COPD and he has COPD exacerbations secondary to COVID19 we use steroids 40 mg per day for 5-7 days
thanks@mohammedmegri for sharing your experience.
Thanks @David_Martin for sharing article, it is helpful.
After the research from UK the benefits of Dexamethasone , our institution is also planning to start the same
I have reviewed the preprint from the RECOVERY trial. I am surprised that based on that data IDSA and SCCM are recommending dexamethasone in COVID-19 ARDS. Our institution has added it as a “consideration”. The data is clearly not strong enough to recommend. There is clear data to recommend AGAINST steroids in COVID-19 if patients are not on oxygen therapy. Due to dexamethasone shortages and concerns from our peds oncology colleagues about availability for them, we are recommending alternatives to dexamethasone if one is considering steroids for ARDS.
We have seen a good response for Dexa in our ICU pt