Covid Intubation Cause Of Panicking?

Perry Staltic

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An interesting convo between doctors about when to intubate. Be sure to scroll to the top for full convo. It's pretty clear to me they most doctors don't know what they're doing. Intubating is an easy way out for them while patients suffer the consequences for their inability/unwillingness to think outside the box and take chances.

A couple of doctors in this convo are trying to gently steer one doctor into realizing that the elevated work of breathing (WOB) seen in covid patients is not necessarily due to hypoxemia, hypercapnia, or low lung compliance (volume), and therefore not like typical pneumonia or ARDS. Dr Jalali is aware that serotonin toxicity causes pulmonary vasoconstriction and fibrosis resulting in impaired gas exchange (hypoxemia) and WOB, and that simply treating with cyproheptadine works to correct that and avoid being intubated by ignorant doctors.

So if he's right, then doctors like the one he's conversing with, who think doctors waiting too long to intubate are allowing patients' lungs to become fibrotic, have it completely wrong. They themselves not treating the cause of fibrosis, i.e., serotonin toxicity, are allowing patients' lungs to become fibrotic where a ventilator will likely do them no good and make them worse.

This is the only way I can get the thread to work. Replace "[dot]" with "." in the link below.

https://twitter[dot]com/farid__jalali/status/1350693646610272265
 
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Perry Staltic

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@Blossom, I read an interesting article today describing a small hospital in the UK. It was mentioned that by the door to the entrance to the ED were syringes of remi, propofol and norad. Is remi remifentanil? I know propofol is serotonergic and remifentanil is too.

I also realized today that EMTs in the US use ketamine quite frequently. It is serotonergic. Also used in hospitals.

 

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So what you're seeing you've seen before, but this time the response is different?
Most people tend to have extreme symptoms when their oxygen is that low but a few with chronic lung/heart issues can become adapted and do not. The people I saw with covid (I stopped working with them at the end of August) low oxygen saturation did not have any of the typical symptoms. They presented more like you would expect of a person adapted to chronic low oxygen.
 

Blossom

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@Blossom, I read an interesting article today describing a small hospital in the UK. It was mentioned that by the door to the entrance to the ED were syringes of remi, propofol and norad. Is remi remifentanil? I know propofol is serotonergic and remifentanil is too.

I also realized today that EMTs in the US use ketamine quite frequently. It is serotonergic. Also used in hospitals.

I *think* it’s short for Remdesivir although that drug wasn’t being used in my area during the first wave.
 

Perry Staltic

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This is the only way I can get the thread to work. Replace "[dot]" with "." in the link below.

https://twitter[dot]com/farid__jalali/status/1350693646610272265

The thread above was a fork off of the main thread. Buried in the main thread is this. Patient saved herself. Doctor treated her with a drug (precedex) used to treat serotonin toxicity.

 
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Perry Staltic

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I *think* it’s short for Remdesivir although that drug wasn’t being used in my area during the first wave.

I'm pretty sure Remdesivir is given IV rather than via syringe. That article mentions remi in 50 ml syringes.

Update: n/m, I'm reading that it's given via injection too.
 
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Blossom

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@Blossom, did/does your hospital use lopinavir/ritonavir (Kaletra), atazanavir, or midazolam (anxiolytic) for covid patients?
I stopped working in the acute care hospital in July and everyone on a ventilator would normally get. Most on vents for any reason (not just covid) do get anti anxiety meds. I don’t remember anyone getting Kaltera but I really didn’t have time to review their entire treatment plan/med list. We were also strongly discouraged to investigate each case by having to put in a special password to review the entire medical chart. You literally had to break in to the computer chart and administration knew if a person was looking at something not strictly related to their scope of practice. I had a really uncomfortable feeling about the whole situation.
 

gaze

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for high risk people who need oxygen, does anyone know how much co2 should be given at the same time for it to be safe? is that even something that can be asked from a doctor? i'm really unfamiliar with how it works, @Blossom any insight? Ray reccomends giving a certain amount of co2 along with it right ?
 

Perry Staltic

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I stopped working in the acute care hospital in July and everyone on a ventilator would normally get. Most on vents for any reason (not just covid) do get anti anxiety meds. I don’t remember anyone getting Kaltera but I really didn’t have time to review their entire treatment plan/med list. We were also strongly discouraged to investigate each case by having to put in a special password to review the entire medical chart. You literally had to break in to the computer chart and administration knew if a person was looking at something not strictly related to their scope of practice. I had a really uncomfortable feeling about the whole situation.

Very interesting. I suspect there's a lot of medipharmacosis going on (ie, iatrogenesis via pharma poisons and ritual intubation). The reason I asked about those drugs is the following viewed in relation to the prolonged times covid patients spend in ICUs.

Finally, the serum concentration of midazolam, which is especially used in the intensive care unit as an anxiolytic, significantly increases in concomitant use with atazanavir or lopinavir/ritonavir. In a retrospective cohort study, in patients taking atazanavir or lopinavir/ritonavir concomitantly with intravenous midazolam, the incidence of severe prolonged sedation and length of hospital stay was significantly longer than in patients not taking any antiretroviral agents.

Do psychotropic drugs used during COVID-19 therapy have an effect on the treatment process?
https://ejhp.bmj.com/content/ejhpharm/early/2020/07/03/ejhpharm-2020-002419.full.pdf (pdf)
 

Perry Staltic

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for high risk people who need oxygen, does anyone know how much co2 should be given at the same time for it to be safe? is that even something that can be asked from a doctor? i'm really unfamiliar with how it works, @Blossom any insight? Ray reccomends giving a certain amount of co2 along with it right ?

Carbogen, but I'd be surprised if they had any on hand, or if any of the doctors would know how to use it. 5% CO2.

I heard a popcast of Ray talking about that, but don't know where to find it now. Any help appreciated.
 

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Carbogen, but I'd be surprised if they had any on hand, or if any of the doctors would know how to use it. 5% CO2.

I heard a popcast of Ray talking about that, but don't know where to find it now. Any help appreciated.
@gaze, I too remember carbogen as what Ray has written/talked about. I’ve never once seen or heard of it used in a medical setting. One small change I have noticed is the trend toward smaller tidal volumes used in mechanically ventilated patients over the last several years as compared to the late 90’s. Although there’s no additional co2 in the oxygen/air mixture the lowering of the tidal volume can result in less endogenous co2 being exhaled.
 

Perry Staltic

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People are also given a sedative prior to intubation and while on a ventilator. This is slowly weaned in preparation to remove the tube. Most people do panic while they are on a ventilator (for covid or something else) if the sedation medication is late or missed for some reason. Being on a ventilator is pretty unsettling due to the tube itself and positive pressure forcing air into the lungs. It’s like blowing up a balloon. Normal breathing is on a negative pressure gradient so it makes sense that the body would perceive air being forced into the lungs as a threat.

Old technology was better... for the patient. Looks like it's coming back,

The exovent uses the same principle as the old iron lungs by creating a negative pressure vacuum around the patient which gently forces air to be sucked into the lungs. It can be used to support patients to breathe or it can take over their breathing completely.

 

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Perry Staltic

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Oxygenation is actually better with negative pressure ventilation. Click on date then Show This Thread under 2nd post for full thread (just above More Tweets).

 

gaze

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@Blossom @Perry Staltic

thank you. So i guess it's really try to avoid the hospital at all costs, cause it probably wouldn't be possible to ask for the proper amount of co2. what's sad is that the nurses themselves are actually often really good people, very caring. I've had some great experiences when I've had to get some work done personally. It's just the medical protocol they are taught is off. I wish we had a more nurturing hospital system, hospitals these days are just too crowded, bureaucratic, and on the wrong path. It's a shame.
 

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@Blossom @Perry Staltic

thank you. So i guess it's really try to avoid the hospital at all costs, cause it probably wouldn't be possible to ask for the proper amount of co2. what's sad is that the nurses themselves are actually often really good people, very caring. I've had some great experiences when I've had to get some work done personally. It's just the medical protocol they are taught is off. I wish we had a more nurturing hospital system, hospitals these days are just too crowded, bureaucratic, and on the wrong path. It's a shame.
Well said, I agree completely. I think it’s best to do everything we can to avoid the hospital. If you do end up admitted for some reason it’s crucial to have someone as your advocate that will ensure your wishes are honored to the greatest extent possible.
 

Perry Staltic

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Well said, I agree completely. I think it’s best to do everything we can to avoid the hospital. If you do end up admitted for some reason it’s crucial to have someone as your advocate that will ensure your wishes are honored to the greatest extent possible.

"Do Not Intubate" in advance medical directive. Be like the woman in the post above who refused intubation, got better and went home without any of the deleterious effects from being tubed.
 

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