Korona virus

[Venera]

nosenje maski vani jeste debilizam

virus se prenosi u zraku ali ako je isti jako koncetriran

To o.koncentraciji ne znamo. Ovoliko broj oboljelih jasno kazuje da je.mjogo infektivniji nego se mislilo i da se prenosi na više načina. Zato jnosi masku i nemoj me.nervirati.

I nemoj mi sad početi nikakve studije, zeludavmc mi je prazan, nervozna sam :asa


Jesi dobro? Kako si?

Iskra, kako si ti , ti radis, ja sam karantirana i zellim se torpedirati

Azija , povijesno, ima ovakave pandemije , i sa SARS CoV i sa SARSCov-1 , a sa ovim SARSCov-2 je brze jer se prenosi sa osobe na osobu , ali i prohodne dvije mutacije su bile pandemicne, a vecina njhovih pandemija traje oko godinu dana, stoga, i ova ce pandemija biti takva , sa nzizim i visim intervalima.

Stoga, nosenje maske vani nema efekta, ako osobe ne vode racuna o drugim, vaznijim fakotrima samozastite

Japan, saocijlna drzava,nema glrnja,nema jubljenja , maske non stop na licu, pa su relativno dobro prosli, ali ih maske nisu spasile kao jedna od kljucnih faktora

[Venera]

nosenje maski vani jeste debilizam

virus se prenosi u zraku ali ako je isti jako koncetriran

Kad porastem zelim biti venera. Strucnjak za sve

ja sma prvi put stavila masku jucer , nos procurio ispodd maske, naocale se zamalge, pa prije cu tako privuci virus u prodavnici

[Iskra]

To o.koncentraciji ne znamo. Ovoliko broj oboljelih jasno kazuje da je.mjogo infektivniji nego se mislilo i da se prenosi na više načina. Zato jnosi masku i nemoj me.nervirati.

I nemoj mi sad početi nikakve studije, zeludavmc mi je prazan, nervozna sam :asa


Jesi dobro? Kako si?

Iskra, kako si ti , ti radis, ja sam karantirana i zellim se torpedirati

Azija , povijesno, ima ovakave pandemije , i sa SARS CoV i sa SARSCov-1 , a sa ovim SARSCov-2 je brze jer se prenosi sa osobe na osobu , ali i prohodne dvije mutacije su bile pandemicne, a vecina njhovih pandemija traje oko godinu dana, stoga, i ova ce pandemija biti takva , sa nzizim i visim intervalima.

Stoga, nosenje maske vani nema efekta, ako osobe ne vode racuna o drugim, vaznijim fakotrima samozastite

Japan, saocijlna drzava,nema glrnja,nema jubljenja , maske non stop na licu, pa su relativno dobro prosli, ali ih maske nisu spasile kao jedna od kljucnih faktora

Drago mi je da si dobro. Ja voćem gladna sam, nemoj, ti opet

[insomnia]

Ti osim sto si pilot takodje si i infektolog. Pod hitno zvati fadila. Jazuk je da takav kalibar sjedi kod kuce

[rocko]

Rocko ajd ti malo objasni oko testiranja
To jest testiraju li vas tamo u toj bogatoj americi cesto i ikako?
I koji je kriterij za testiranje?

To ti zavisi od drzave do drzave jer test koji se radi je neugodan , bris nosa mi smo testriali 1/20 ukupne populacije koju bolnica u regiji pokriva, ovo su standardi :

PRIORITY 1
Ensure optimal care options for all hospitalized patients, lessen the risk of nosocomial infections, and maintain the integrity of the healthcare system

Hospitalized patients
Symptomatic healthcare workers
PRIORITY 2
Ensure that those who are at highest risk of complication of infection are rapidly identified and appropriately triaged

Patients in long-term care facilities with symptoms
Patients 65 years of age and older with symptoms
Patients with underlying conditions with symptoms
First responders with symptoms
PRIORITY 3
As resources allow, test individuals in the surrounding community of rapidly increasing hospital cases to decrease community spread, and ensure health of essential workers

Critical infrastructure workers with symptoms
Individuals who do not meet any of the above categories with symptoms
Health care workers and first responders
Individuals with mild symptoms in communities experiencing high COVID-19 hospitalizations
NON-PRIORITY
Individuals without symptoms

[Beni]

nosenje maski vani jeste debilizam

virus se prenosi u zraku ali ako je isti jako koncetriran

Kad porastem zelim biti venera. Strucnjak za sve

Iltiga Vegeta

[Venera]

Iskra, kako si ti , ti radis, ja sam karantirana i zellim se torpedirati

Azija , povijesno, ima ovakave pandemije , i sa SARS CoV i sa SARSCov-1 , a sa ovim SARSCov-2 je brze jer se prenosi sa osobe na osobu , ali i prohodne dvije mutacije su bile pandemicne, a vecina njhovih pandemija traje oko godinu dana, stoga, i ova ce pandemija biti takva , sa nzizim i visim intervalima.

Stoga, nosenje maske vani nema efekta, ako osobe ne vode racuna o drugim, vaznijim fakotrima samozastite

Japan, saocijlna drzava,nema glrnja,nema jubljenja , maske non stop na licu, pa su relativno dobro prosli, ali ih maske nisu spasile kao jedna od kljucnih faktora

Drago mi je da si dobro. Ja voćem gladna sam, nemoj, ti opet

moram,evo food for thougth:

Ceskoj skinut zakon o maskama, jer im je krivulja zadovoljena

tko to garantuje populaciji sa jednom statistikom , jer se ista kosntatno mjenja,a znatno ce se promjeniti u Maju, kad se ponovo pokusa nomrlaizirati zivot u Evropi

[rocko]

To o.koncentraciji ne znamo. Ovoliko broj oboljelih jasno kazuje da je.mjogo infektivniji nego se mislilo i da se prenosi na više načina. Zato jnosi masku i nemoj me.nervirati.

I nemoj mi sad početi nikakve studije, zeludavmc mi je prazan, nervozna sam :asa


Jesi dobro? Kako si?

Iskra, kako si ti , ti radis, ja sam karantirana i zellim se torpedirati

Azija , povijesno, ima ovakave pandemije , i sa SARS CoV i sa SARSCov-1 , a sa ovim SARSCov-2 je brze jer se prenosi sa osobe na osobu , ali i prohodne dvije mutacije su bile pandemicne, a vecina njhovih pandemija traje oko godinu dana, stoga, i ova ce pandemija biti takva , sa nzizim i visim intervalima.

Stoga, nosenje maske vani nema efekta, ako osobe ne vode racuna o drugim, vaznijim fakotrima samozastite

Japan, saocijlna drzava,nema glrnja,nema jubljenja , maske non stop na licu, pa su relativno dobro prosli, ali ih maske nisu spasile kao jedna od kljucnih faktora

U Japanu tek krece , Tokio se sprema da bude gori od NYC ,
Zar je moguce da nisi posjetila Japan ?

Razocarala si me a i njega

[Venera]

Ti osim sto si pilot takodje si i infektolog. Pod hitno zvati fadila. Jazuk je da takav kalibar sjedi kod kuce

nisam, ali d virusa ne mozemo pobjeci

[MunDzi]

Joj da hoce vise ispiti ovu kafu.

[insomnia]

O naravno da mozemo

[Venera]

O naravno da mozemo

ne mozemo

[spacebound]

Rocko, mogu nesto da te pitam, dugo ja vec imam dileme oko toga? Mozda je i glupo, ne znam. Uglavnom, tice se respiratora, ventilatora. Da li je ova masina ista, to su vjestacka pluca. Radila sam na odjelu sa takvim pacijentima.

[Beni]

Ti osim sto si pilot takodje si i infektolog. Pod hitno zvati fadila. Jazuk je da takav kalibar sjedi kod kuce

Uskoro Venera se obraca umjesto Solaka gradjanima FBiH

[rocko]

Nije glupo, nema glupog pitanja ,

to ti je to masina koja dise za pacijenta koji nije u stanju da dise spontano posto Covid izaziva ARDS i pacijent nije ustanju da dise onda mora na ventilator.

[Venera]

spacebound, Isrka,Vila

From the Head of ICU at the Royal Free. Please feel free to disseminate further.
“Dear All,
I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases.
The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton.
Ventilation
- Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness.
- Avoid spontaneous ventilation early in ICU admission as also may be harmful.
- There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space.
- Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related.
- Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation.
- Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT.
- Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier.
- Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting.
- Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days.
- Generally people are using humidified circuits with HMEs.
- A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily.
- Leak test before extubation is crucial, others are also seeing airway swelling.
- Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high.
My conclusions from this are:
- Less aggressive PEEP strategy at the beginning of the disease and go straight for proning.
- Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky.
- An extubation protocol is needed immediately.
- We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.
Fluid balance
- All centres agreed that we are getting this wrong.
- Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated.
- High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF.
- Hypovolaemia leads to poor pulmonary perfusion and increased dead space.
- Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure.
- Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic.
[On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.]
- Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance.
- Lung ‘leak’ not as prominent in this disease as classic ARDS
My conclusions from this are:
- Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality.
- Avoid hypervolaemia
- How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients.
- Echo patients to understand their volume status.
Renal
- Higher than predicted need for CVVHF - ? Due to excess hypovolaemia.
- Microthrombi in kidneys probably also contributing to AKI.
- CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps.
- Kings now beginning acute peritoneal dialysis as running out of CVVHF machines.
My conclusions from this are:
- Aggressive anticoagulant strategy required for CVVHF, potentially systemic.
- If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines)
Workforce
- A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients.
- Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU.
- Training has largely fallen by the wayside as it is too large a task. People are being trained on the job.
My conclusions from this are:
- On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted).
- We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable.
There were some brief discussion about CPAP:
- Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders.
- Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU.
- Considerable oxygen supply issues with old school CPAP systems.
My conclusions from this are:
- As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation.
- If effective, regular review is required. If at any point it is failing, bail out and consider ventilation.
- Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure.
OK, that’s all I have.
I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs.
My conclusions after each section are nothing more than suggestions to be discussed.
We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required.
Lastly, we desperately need to look at our own data to understand whether we are getting this right or not.
Good luck, stay stay safe and be kind to one another.
Dan
Daniel Martin OBE
Macintosh Professor of Anaesthesia
Intensive Care Lead for High Consequence Infectious Diseases
Royal Free Hospital
London

[Zana]

[rocko]

spacebound, Isrka,Vila

From the Head of ICU at the Royal Free. Please feel free to disseminate further.
“Dear All,
I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases.
The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton.
Ventilation
- Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness.
- Avoid spontaneous ventilation early in ICU admission as also may be harmful.
- There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space.
- Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related.
- Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation.
- Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT.
- Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier.
- Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting.
- Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days.
- Generally people are using humidified circuits with HMEs.
- A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily.
- Leak test before extubation is crucial, others are also seeing airway swelling.
- Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high.
My conclusions from this are:
- Less aggressive PEEP strategy at the beginning of the disease and go straight for proning.
- Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky.
- An extubation protocol is needed immediately.
- We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.
Fluid balance
- All centres agreed that we are getting this wrong.
- Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated.
- High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF.
- Hypovolaemia leads to poor pulmonary perfusion and increased dead space.
- Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure.
- Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic.
[On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.]
- Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance.
- Lung ‘leak’ not as prominent in this disease as classic ARDS
My conclusions from this are:
- Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality.
- Avoid hypervolaemia
- How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients.
- Echo patients to understand their volume status.
Renal
- Higher than predicted need for CVVHF - ? Due to excess hypovolaemia.
- Microthrombi in kidneys probably also contributing to AKI.
- CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps.
- Kings now beginning acute peritoneal dialysis as running out of CVVHF machines.
My conclusions from this are:
- Aggressive anticoagulant strategy required for CVVHF, potentially systemic.
- If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines)
Workforce
- A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients.
- Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU.
- Training has largely fallen by the wayside as it is too large a task. People are being trained on the job.
My conclusions from this are:
- On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted).
- We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable.
There were some brief discussion about CPAP:
- Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders.
- Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU.
- Considerable oxygen supply issues with old school CPAP systems.
My conclusions from this are:
- As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation.
- If effective, regular review is required. If at any point it is failing, bail out and consider ventilation.
- Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure.
OK, that’s all I have.
I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs.
My conclusions after each section are nothing more than suggestions to be discussed.
We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required.
Lastly, we desperately need to look at our own data to understand whether we are getting this right or not.
Good luck, stay stay safe and be kind to one another.
Dan
Daniel Martin OBE
Macintosh Professor of Anaesthesia
Intensive Care Lead for High Consequence Infectious Diseases
Royal Free Hospital
London

Sta kaze raja sa pulomologije na ovo sve?

[vila]

Venera ne stojim ti bas dobro sa citanjem engleskog
Pogotovo ne sa takvim tekstom prepunim strucnih pojmova
Al svejedno...opet stoji da vise nemam nista reci na ovoj temi

[MunDzi]

spacebound, Isrka,Vila

Sta kaze raja sa pulomologije na ovo sve?

Kaze da je 786 mrtvih u UK u zadnjih 24 sata.
Ne znam sta su to tako pametno zakljucili pa im ona dize palac gore.
Ja bih gledala sta Svabe rade, jer je njihov ratio zarazenih i mrtvih povoljniji.