Top 10 Things I learned Treating COVID ICU Patients | COVID ICU

Welcome, Doctor Mike Hansen here and in this video  I'm going to talk about some of the things that   I've learned while working in the covid ICU unit.  so some intensive care units at various hospitals   throughout this country have designated units for  covid 19 patients and as an intensive care doctor   myself I've been seeing a lot of covid patients  and are designated to covid ICU it's one thing to   read about covid in the medical literature but to  be actually seeing real patients with disease is   a whole nother experience altogether there are  lots of things I've learned but for this video   I'm gonna focus on the top ten that stand out to  me so starting at the bottom with number 10 is   I'm gonna talk about the signs and the symptoms  so the most common symptoms that I'm seeing are   fever cough shortness of breath and body and  muscle aches I haven't seen many patients with   other symptoms we often hear about such as loss  of taste and smell or nausea and diarrhea I've   not seen any rashes related to Covid probably  because I only see adult patients I will say   that even though confusion and delirium is  very common in the intensive care unit in   general there does seem to be more of that with  Covid so a lot of Covid 19 patients who require   hospitalization do have low vitamin D levels  and this is consistent with what we're seeing   and a lot of the recent studies that have been  coming out but of course correlation doesn't   necessarily mean causation so does it just so  happen that a lot of patients who have moderate   or severe kovat happen to have low vitamin D  levels maybe maybe not and does that mean that   we should give every hospitalized patient with  covid big doses of vitamin D when they hit the   door maybe and does that mean people in general  should supplement with vitamin D and what is the   ideal level of vitamin D for the population  especially when it comes to covid should we   be targeting the current general recommendation  for everyone irrespective of covid with a goal   of 20 MGS per ml or should we aim for a higher  like 30 or perhaps 40 no one knows for sure the   answers to these questions but there are studies  being done on this and as we speak there are three   randomized control trials for vitamin D in Covid  I take a further deep dive into vitamin D and   some of my other videos on this channel so if you  want you can check those out so number eight this   iris is very contagious one of my patients was in  the hospital for unrelated reasons she actually   had sepsis due to infarct that gut meaning part of  her intestine was not getting enough blood flow it   was so severe to the point that some of the tissue  in her tessen had died off when this happens the   bacteria that live in the intestine could then  invade the walls of the intestine and get into   the bloodstream this is bad news because these  bacteria can then spread throughout the body and   this is known as sepsis so besides antibiotics  this is treated with surgery where the dead gut   tissue is removed meaning part of the intestine  is taken out and this is what happened with her   and she got better but after she initially got  better she started having more difficulty with   her breathing her oxygen levels are dropping  despite us giving her more and more oxygen so   we got a chest x-ray and later a cat scan of the  chest which showed bilateral infiltrates meaning   areas of inflammation in both lungs and this is  the pattern we typically see with Covid pneumonia   where it tends to go to the periphery of the  lungs and also more so at the bottom of the   lungs so we tested her for covid and sure enough  the PCR test came back positive unfortunately she   did not survive so how did she get covid no one  really knows of course she got in the hospital   but there weren't any known healthcare workers  who had Covid and she did not have any visitors   because of the visitor policy so it's a mystery  as to how this stealthy virus was transmitted to   her which speaks to just how contagious the virus  really is I've also seen entire families who live   under one roof all hospitalized so yeah pretty  contagious and that leads me to number seven   which is because of the no visitor policy it  sure is lonely for patients in the hospital and   it's incredibly hard for family members to not be  with their loved ones especially when they may not   survive so as if dying is not bad enough some  of them die alone which is obviously horrible   based on my experience it's hard to really get a  gauge on the treatments that we give so for most   patients depending on individual circumstances  we're giving remdesivir convalescent plasma   dexamethasone and even therapeutic doses of blood  thinners so for the blood thinners meaning in   psycho agya Latian giving lovenox AKA enoxaparin  if their kidney function is okay or alternatively   if their kidney function is not okay we give  another blood thinner like heparin we still   don't know for sure who we should be treating  with full doses of blood thinners because it's   usually not practical to try and diagnose blood  clots and someone who's sick with covid in the   hospital there are various reasons for this one  there's no single test that can definitively   diagnose clots in the body every test that looks  for clots either with an ultrasound of the leg   or CT angiogram of the chest or a VQ scan of the  lungs or CT scan of the brain looking for stroke   or a blood test checking the d-dimer all of these  things can have false negatives not only that but   for each of these tests they all have their own  risks for example with a CT angiogram not only are   you giving them the radiation from the cat scan  but you're also given them contrast which means   they could potentially have an allergic reaction  or they can also get some kidney damage from   that contrast never mind the potential spread  of the virus when you move the patient to the   CT scanner so because of the incidence of blood  clots and Covid patients who have severe disease   it's tough to be around 30 to 40 percent or so  most ICU doctors including myself are opting to   just empirically treat all covid patients in the  ICU with therapeutic doses of blood thinners now   the downside of course is the risk of bleeding so  it's a judgment call at this point some doctors   also base their decision on how high the d-dimer  level is but again we simply don't know at this   point if we should do that or not but we do see  a lot of clots and patients I had one patient   who had severe covid to the point of requiring a  ventilator it was also severe enough to the point   of causing our kidneys to shut down when we were  doing dialysis on her the Machine kept clogging   up with blood clots and later on we were able to  take out the breathing tube once her breathing   finally got better but something was off with her  from neurologic standpoint now I really don't like   sending covid patients to the cat scan because  then you risk spreading the virus throughout the   hospital but sometimes you have to do it and in  this case I did I ended up biting the bullet and   sure enough she unfortunately had a stroke and  as far as all the other treatments I mentioned   including convalescent plasma I can't really say  one way or another if they're making a difference   if they are making a difference it's not obvious  it's not like you give any of these treatments   and patients are all of a sudden magically better  so that's why we always need scientific studies   in the form of a randomized controlled trials to  really know if a treatment is working or not so   for number five I'm gonna go with testing I think  testing is still a guessing game at this point one   of my patients who is in ICU for more than 20 days  so he initially tested positive with the PCR test   and then we ended up retesting him about three  weeks after that and he again tested positive   so does that mean he can still spread the virus  to other people maybe or it just might be that   the PCR test is picking up the inactivated viral  RNA and these viral remnants are causing the test   to be positive even though it's possible he's  no longer shedding the virus all right number   four a lot of my Covid patients are obese or  morbidly obese and here's the thing a lot of   people who are obese have obstructive sleep apnea  and a lot of people who are obese especially if   they're morbidly obese have something called  obesity hypoventilation syndrome which is a   fancy way of saying that they're not able to  breathe off as much carbon dioxide as they   should because of their body habitus sometimes  when an obese patient is in the hospital and   we suspect they have obstructive sleep apnea we  give them a CPAP machine to use at night or if   they have obesity hyperventilation syndrome we  give them a BiPAP machine which is essentially   the same thing as CPAP except instead of blowing  air into the mouth and nose using one constant   pressure the BiPAP does two different pressures  one at a higher pressure and then one at a lower   pressure so the higher one is for inhalation  while the lower pressure is for exhalation in   fact that's what BiPAP means by level positive  airway pressure well when someone is covid   positive that kind of throws a wrench into our  plans because CPAP and BiPAP generate aerosols   in the room which means you can potentially have  that virus being thrown around the room from the   CPAP or the BiPAP so that means the patient would  have to be transferred to a negative airflow room   and negative airflow rooms are limited so they may  not be available especially in times of a pandemic   that's what makes the surge in cases recently  all the more cancer because more cases means   more hospitalizations which of course means less  negative airflow rooms less ICU rooms available ok   number three on the list is mechanical ventilation  so a couple things with this one it's still really   hard to know when or if we should intubate someone  meaning put a breathing tube down someone's throat   some patients have very low oxygen levels while  not necessarily being in respiratory distress   meaning they may not feel short of breath or have  air hunger or they're not necessarily breathing   that fast and deep so the question becomes how  low are we willing to let their oxygen levels go   before we decide on putting their breathing tube  in so the decision to intubate is much easier   when someone is in respiratory distress once the  patient is intubated the settings that we dial   in on the ventilator really have to be catered  towards that patient and while this is true of   intubated patients in general this is even more  so with Kovac because of the variability of their   lung disease meaning some patients might have  more inflammation in ARDS compared to others   while other patients might have more blood clots  and less inflammation so some patients might be   obese while others might not be obese there are  really so many factors that go into how we manage   patients on the ventilator so it's pretty common  we're really tinkering around with those vent   settings trying out different modes on their  different settings so some patients do better   when they're prone and others not so much some  patients need to be given a paralytic medication   in order to be synchronous with the ventilator  while others don't need paralytics so it's not   one-size-fits-all with all these patients and  some patients don't need the ventilator while   others might only need it for a couple days while  others need it for weeks and when someone needs a   ventilator for a few weeks or longer that's when  we need to do a tracheostomy meaning make a small   hole in neck to fit a smaller size breathing tube  we do this because the original breathing tube   meaning the endotracheal tube can only be left  in for so long before the risk of complications   from that really start to climb typically the  arbitrary cutoff is two weeks but with covid  we're generally waiting for three weeks all right  number two recovery so as an intensive care doctor   I see patients in the intensive care you but as  a pulmonologist meaning a lung doctor I also see   patients in the pulmonary clinic so I'm able  to follow patients who have not only had covid  and that ICU but then see how they do in their  recovery in the pulmonary clinic afterwards I   had a young patient in his 40s who was not obese  and who was otherwise healthy who was on the cusp   of requiring a breathing tube when he was in the  hospital his cat scan showed the pneumonia in both   lungs ultimately he didn't require the breathing  tube and he slowly got better but he needed to   be discharged home with supplemental oxygen and  he's still not 100% back to normal and this is   now three months after he first got the virus  thankfully he's alive but his lungs suffered a   lot of damage will his lung function fully recover  I don't know only time will tell sometimes with ARDS   due to viral pneumonia there can be permanent  damage but lots of times a damage from all the   inflammation there slowly gets better with time  and something I forgot to mention is he actually   had something pretty unusual happened to him not  that it's unheard of but it's pretty uncommon for   it to happen and that is he developed something  called a new marrow seal as a result of having   pneumonia so what is a new Maddison it's a cyst in  the lungs that develops after an infection and or   ARDS acute respiratory distress syndrome a cyst  is a thin walled bubble if you will now in his   case it really formed between the upper and middle  lobe of his right lung but because of the fluid   that we can see inside there was the possibility  that this was an abscess and that's why we treated   him with an antibiotic especially because he  was having pain in the right side of his chest   especially when he would take a deep breath the  pain would actually become worse so this is known   as pleuritic chest pain oh and here's a fun fact  for you did you know that the lungs themselves   don't have pain receptors however the lining of  the lungs called the pleura do have pain receptors   so anything that disrupts the pleura can cause  pain so this can include adjacent pneumonia in   the lungs and in this patients case it was the  cysts and possibly abscess that was irritating   the pleura the lining of the lung and this was  causing his chest pain but getting back to some   of my other patients who had severe covid some of  them required nation for a few weeks and survived   and some of them required a tracheostomy while  others did not so why some people have worse   disease and others still hasn't been sorted  out yes we know that severe disease is more   likely with older age or other medical problems  like diabetes high blood pressure obesity type   A blood but we don't know why is viral load part  of the reason may be I'm sure genetics are a big   part of as well but we don't know what specific  genes or genetic variations okay number one on   this list is unpredictability and variability  of this virus and this disease so this virus   and this disease is just so unpredictable in  so many ways who gets sick the variation of the   symptoms the variation and severity of disease  the variability of timing where someone can be   relatively fine all of a sudden and then BOOM  within hours they require a breathing tube how   some people get more inflammation while others get  more clots how some people recover quicker than   others how some people have the disease but their  test is negative meaning they have false negative   so we're all still learning about this virus and  this disease in real time and there's a lot to   learn and hopefully we can get a vaccine for this  that is both safe and effective and hopefully   enough people get the vaccine for herd immunity to  take place but a vaccine itself is not a guarantee   especially because we don't know how long these  coronavirus antibodies are protective and there   are more and more drugs being studied and some  look more promising than others but only time   will tell with more randomized control trials but  for now we have to social distance and use masks   because that's the only thing we have at this  point and this virus isn't going away anytime   soon but anyway thanks for watching this video I  have more videos on the way of course I think the   next one's going to be on convalescent plasma so  check that out and I will see you in the next one

Channel: Doctor Mike Hansen

Views: 1,734,188

Keywords: covid icu patients, covid icu, covid doctor, covid patients, icu covid, icu covid patients, covid patients on ventilators, covid intensive care, covid intensive care unit, dr mike hansen, doctor covid, treating covid, how to treat covid, covid treatment in icu, covid ventilator, covid treatment protocol, covid intubation, covid icu ward, covid patient on ventilator, treat covid, covid treatments, icu covid patient, covid icu intubation, covid critical patients, covid

Id: w-NZeaEKRng

Length: 15min 32sec (932 seconds)

Published: Thu Jul 02 2020