COVID Academy

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Orders

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BRAVE NEW WORLD
(this is a work in progress – the site updates daily – check back in a week if you’re not pleased))

COVID-19 has turned the medical world on its head. Communication between teams, clinicians, and patients has changed radically. Many of our daily tasks are temporarily forbidden. And many of us will be called on to play roles far outside our comfort zones. Welcome to our brave new world. 

One of the most intimidating tasks,  will be providing care in acute care settings including the ICU. Physicians in many disciplines are being ask to repurpose themselves to deal with the pandemic in crisis zones. As absurd as it sounds at first blush, I can reassure you that most physicians can be rapidly retrained to play a meaningful role in such settings. 

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COVID Academy

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COVID ACADEMY

A primer for docs called back to the front line.

Most physicians deal with uncertainty, complexity, and untoward medical outcomes on a daily basis – often with little to no perceived stress. We are spared the panic because the terrain is familiar, and we have a plan – something to do to try and make things better.

The goal of this section is to give bring you up to speed on COVID-19, to remind you how critical care settings work, and to provide you with approaches and tools to do the things you have to do like:

  • Examen the patient
  • Order an investigation
  • Identify multi organ dysfunction
  • Estimate and track patients progress and prognosis
  • Write notes and order ICU medications
  • Talk to family members

As foreign or as impossible as this may sound, you can do this. Your medical training and experience will help as will your ability to deal with complexity and ambiguity which is present throughout medical practice.

Remember that we can teach medical students and residents to do this sometimes in less than a month. You CAN do this too!

 

ORDER SETS
How to use this section

This section of the site is intended is educational and pragmatic.

Its purpose is to demonstrate what typical orders and prescriptions look like primarily on students, residents and in physicians returning to an acute care setting.

If you work in a structured critical care setting, it is very likely that most of the information covered in this section is already covered by protocols of the unit. In such cases you should alost always stick with the protocols in place. However the education elements of each Tab may still be of interest.

If the unit that you are working is does not have protocols and you are be drafted into a critical care setting – this section could save you a lot of time.
The Rx parts of each tab are designed to be cut and pasted or transcribed directly into whatever tool you use to write orders. Often they will require MINOR modifications – for example in adjusting norepinephrine (a drug to increase blood pressure or BP), you need to signal the target BP. Usually a placeholder is left to clue you in visually to fill in the number. This could be either a a series of underscores  _______ or capitalized Xes.   ie XXXXX.

 

CAVEAT!!!!!

These orders have been checked multiple times by multiple people in multiple professions. However, as we all know people are not perfect – and neither are machines. Errors could be introduced at any step including on the user end if these Rxs are cut and pasted or copied into your chart. There is also a risk that the dosing in these order sets are not the same as the standard doses in the unit where you work.  In this spirit of patient safety we urge vigilance on for all prescribers. Make sure that the doses provided make sense, and have them confirmed by hospital pharmacists. If you spot an error on the site, please contact me through the contact form at www.saineville.com/contact

Investigation for stable patient with risk factors or symptoms suggestive of COVID-19

Content coming

Admission orders to ward for patients with suspected COVIDS

Coming

COVID-19 Admission Orders to ICU

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Common ICU meds: Vasoactive perfusions
Norepinephrine (Levophed) [𝛼 and ß agonist causing potent vasoconstriction, inotropy and chronotropy]

Low dose norepinephrine (for infusion in peripheral veins)
4 mg/250 cc NS [1 cc/hr = 0,25 micrograms per minute]

Titrate to target MAP of _____ (60-70 is common use*). Adjust according to verbal order from physician if patient instable or if stable increments of 1-5 cc q 5 minutes

or

Intermediate dose norepinephrine
8 mg/250 cc NS [1 cc/hr = 0,5 micrograms per minute]
Titrate to BP target of MAP of _____ (60 -70*) is a common target). Adjust according to verbal order from physician if patient instable or if stable increments of 1-5 cc q 5 minutes

Or

Hi dose norepinephrine
16 mg/250 cc NS [1 cc/hr = 1 micrograms per minute]
Titrate to BP target of MAP of _____ (60-70*). Adjust according to verbal order from physician if patient instable or if stable increments of 1-5 cc q 5 minutes

 

TEACHING NOTES:
Norepinephrine is a potent vasoconstrictor and for many intensivists the first agent of choice for BP support in septic shock (it is the pressor of choice according to the 2020 COVID-19  Surviving Sepsis campaign). It is an adjunt to volume, but often in COVIDs and other septic patients we want to keep patients dry to mitigate avoid or mitigate ARDS.

The effect of Norepinephrine is similar across all doses and there is no physiologically based lower or upper limit to the dose. The sicker they are the more they will need. KEEP IT SIMPLE – You don’t need to calculate based on body weight unless the IV pumps in our hospital are require it. Start with a low, intermediate, or high dose depending on the stability of the patient and titrate rapidly until stability is achieved. The onset of the drug is extremely rapide (seconds)  and its effects last 1 – 2 minutes. Be careful, if you loose the line you could loose the patient. 

TARGET:
Short acting i.v. vasoactive drugs are prescribed to be titrated to meet a BP target usually measured by the calculated mean arteriel pressure (MAP). Most intenvists target a MAP of 60 – 70 for sepsis. The Surviving Sepsis Campaign (SSC), recommends a MAP target of 60 – 65 for most patients. nb – these are guidelines. Physicians can always deviate from generic guidelines using their clinical judgement. For example if your chronically hypertensive patient pees at a mean MAP of 70 but not at 60, you should probably aim for a MAP of 70).

 

The practical upper limit is defined by the lack of an effect. If you have no effect with a high dose of epinephrine ie 16mg/250 cc NS at 20 – 30 cc/h then you may want to go higher while starting other drugs to boost blood pressure. Options could include:

  • Dobutamine
  • Vasopressin, or
  • Corticosteroids (eg solucortef)

Sometimes very high doses are required to achieve the BP target. If so, the dose can be raised ie double dose, quadruple dose, etc. This also limits the volume delivered to the patient possibly preventing or limiting pulmonary oedema.

CAVEATS:
NOREPINEPHRINE is a powerful lifesaving drug but it is NOT benign. It can cause malignant arrhythmias, tachycardia, bradycardia, malignant arrhythmias, and ischemia. In high doses it is usually given through a central line, but it is increasingly popular to initiate therapy using a peripheral line (often in dilute concentrations). Extravasation from a peripheral  i.v. can cause limb schema and should be promptly treated with sympathetic blocade. Mix 5–10 mg of phentolamine mesylate (an α-adrenergic blocking agent) in 10  – 15 ml of NS and inject s.c. covering the involved areas.

Dobutamine [ ß agonist causing increased cardiac contractility (inotropy) and vasodilation]

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Phenylephrine

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Vasopressin

Vasopressin is an innate vasoactive agent with multiple receptors and modes of action. It has been used to treat multiple diseases including: cardiac arrest, distributive (septic) shock, Variceal bleeding, and bleeding from VWD, amngst others.

Supplied 1 amp = 20 U (in 1 ml)  = 0,4 mg
Time to onset
Half life

Here are the conventional doses:

Septic Shock    

VASSOPRESSIN – 2 AMPS (40 U) in 100 ML NS 0,4 U/ML 
Perfuse at 5 CC/HR   (2 U/HRr = 0,034 U/min)

 

40 U bolus in arrest – removed from ACLS in 2016 to simplify

 

IV 0,03 U/min  = 1,8 U/h 

2 amps = 40 U / 100 cc   0,4 U/cc   5 cc per hour =2 U/h = 0.034 

ORDER SETS - français (work in progress)
How to use this section

This section of the site is intended is educational and pragmatic.

Its purpose is to demonstrate what typical orders and prescriptions look like primarily on students, residents and in physicians returning to an acute care setting.

If you work in a structured critical care setting, it is very likely that most of the information covered in this section is already covered by protocols of the unit. In such cases you should alost always stick with the protocols in place. However the education elements of each Tab may still be of interest.

If the unit that you are working is does not have protocols and you are be drafted into a critical care setting – this section could save you a lot of time.
The Rx parts of each tab are designed to be cut and pasted or transcribed directly into whatever tool you use to write orders. Often they will require MINOR modifications – for example in adjusting norepinephrine (a drug to increase blood pressure or BP), you need to signal the target BP. Usually a placeholder is left to clue you in visually to fill in the number. This could be either a a series of underscores  _______ or capitalized Xes.   ie XXXXX.

 

CAVEAT!!!!!

These orders have been checked multiple times by multiple people in multiple professions. However, as we all know people are not perfect – and neither are machines. Errors could be introduced at any step including on the user end if these Rxs are cut and pasted or copied into your chart. There is also a risk that the dosing in these order sets are not the same as the standard doses in the unit where you work.  In this spirit of patient safety we urge vigilance on for all prescribers. Make sure that the doses provided make sense, and have them confirmed by hospital pharmacists. If you spot an error on the site, please contact me through the contact form at www.saineville.com/contact

COVID-19 SEDATION Orders - ICU CONTEXTE COVID-19 (pénurie Rx anticipée)

SEDATION — CIBLE: Échelle de Richmond ( RASS  -5 à +4) : ____________   (pour patient entubée visée -2 (sédation légère) à 4 (sédation profonde): selon l’état du pt)

• Réévaluer la sédation q 4 h
• Si CIBLE non atteint : ajuster la dose des sédatifs de 10 à 20% à la hausse ou à la baisse, selon le cas
• Aviser le médecin si CIBLE non atteint malgré doses maximales de sédation
◻ Cesser les sédatifs IV chaque matin à 7 h et les redébuter à 50% du débit lorsque le patient atteint un RASS 0

RX :
◻ LORAZEPAM 0.2 mg/ml (10mg dans 50mL de D5%), perfusion IV à __________ mg/h (dose de départ 0,5 à 2mg/h)
(conversion 1mg lorazépam = 5mg midazolam)                                        Max : _____ mg/h (maximum 6mg/h incluant les bolus IV)
◻ Bolus IV de _______ mg aux _____ minutes PRN pour atteinte de la cible visée

◻ MIDAZOLAM 1 mg/ml (100mg dans 100mL NS), perfusion IV à _____ mg/h (dose de départ 2,5 à 10 mg/h)
    (conversion 1mg lorazépam = 5mg midazolam)                              Max : _____ mg/h
◻ Bolus de _______ mg IV aux _____ minutes PRN pour atteinte de la cible visée

◻ PROPOFOL 10 mg/ml, perfusion IV à ______ mg/h      Max : ______ mg/h  (max 4 mg/kg/h incluant les bolus)
◻ Bolus de _______ mg IV aux _____ minutes PRN pour atteinte de la cible visée

◻ DEXMÉDÉTOMEDINE  4 mcg/ml, perfusion IV à ______ mcg/kg/h     Max : ______ mcg/kg/h (maximum 1,2 mcg/kg/h)
Ajustement par paliers de 0,1 mcg/kg/h aux 15 à 30 minutes selon le niveau de sédation visé

THÉRAPIES SÉDATIVES D’APPOINT (PO ET I.V.)
PER OS
◻ DIAZEPAM ____ mg PO aux ____ h régulier (dose suggérée: 5 à 10 mg; intervalle suggéré q6-8h; attention s’accumule)
◻ LORAZEPAM ____ mg PO aux ____ h régulier (dose suggérée: 1 à 2 mg; intervalle suggéré q4-6h)
◻ MÉTHOTRIMÉPRAZINE (Nozinan)  _____ mg PO aux _____ h régulier  (dose suggérée : 12,5 à 25mg;  intervalle suggéré : q 6-8h; attention effet anticholinergique; conversion 2 mg PO = 1 mg IV)

INTRAVENEUSE:
◻ KETAMINE 2 mg/mL (200mg dans 100mL de NS), perfusion IV à _____mg/h (dose de départ 0,1 à 0,5 mg/kg/h)
◻ MÉTHOTRIMÉPRAZINE (Nozinan)1 mg/mL (100mg dans 100mL de NS), perfusion IV à _____mg/h (dose variant de 2 à 8 mg/h)
◻ PHÉNOBARBITAL ______ mg IV aux ____ h régulier (dose suggérée : 30 à 120 mg; intervalle suggéré : q 6-8h; attention s’accumule)

◻ Autre : ______________________________

Common ICU meds: Vasoactive perfusions