CoVid19 Part XI - 2,615 in ROI (46 deaths) 410 in NI (21 deaths)(29/03)*OP upd 28/03*

Interesting read from a health sector worker in the UK.




I'll be honest, as I see it due to working in Intensive Care. The lack of ventilators, which the government is falling over itself to sort, is not the biggest issue at the moment, it'll be the lack of suitably trained people to operate the ventilators effectively, as part of overall care for a critically unwell patient.

You can give (and we are) non-Intensive Care nurses basic training on ventilators but, as experience is showing, many Covid-19 patients that are being ventilated on Intensive Care Units are effectively in multi organ failure, requiring wider treatment than 'just' ventilation.

Even those patients who aren't in multi organ failure require more complex treatment regimes due to the nature of the high pressures required for effective ventilation and to keep patients as sedated as we can in order that they are compliant with the ventilation settings.

(My apologies but some 'shop talk' will appear now, I'll link to articles explaining what I'm talking about where I can)

We are having to heavily sedate patients far deeper than the levels we usually aim for.

Usually we try to sedate patients to a RASS of 0 to -2, which means patients are very lightly sedated, often able to breath spontaneously under the sedation. This helps maintain strength in muscle groups required for breathing and means that hospital stays are shortened, less rehabilitation is required and patients outcomes are overall much better.

With Covid-19 though we are having to ventilate patients with much higher pressures than we normally would in order to counter the effects of the pneumonia that it causes. These higher pressures cause issues with patients not 'sycronising' with the events, in short because the body finds it uncomfortable and triesto resist (desyncronising). As a result we're generally having to sedate patients to a RASS of-4 to -5 (so-called "flattening them out") and are very often also having to use paralysing medications to ensure total compliance.

This level of sedation then introduces other issues, predominately sedation-related hypotension (low blood pressure), for which we then have to give other medications (inotropes) in order to vasoconstrict the vascular system and keep blood pressure high around the core organs to keep them perfused (well oxygenated via blood flow).

Using inotropes though has a knock-on issue of it's own, or rather two predominate ones; lower blood pressure in kidneys and poor blood flow at the extremities. The former causes a reduction in urine production, leading to poor excretion of harmful waste products within the blood stream, the latter can lead (in extreme case) to necrosis (cell death from oxygen starvation).

To add to this, we are unable to directly treat Covid-19 as there is currently no cure, so we're relying upon patients own immune system to deal with it. This causes other issues, among them; the immune response requiring large amounts of glucose to be released into the blood system to 'feed the body' and, as a consequence of so much glucose being used metabolically, an increase in the amount of Ketones within the blood.

The large amount of glucose needs to both be supplemented (through Nasogastric Feeding) and controlled (with Insulin) to try and restrict the levels of blood glucose. If left unchecked the body will just keep glucose (causing Hyperglycemia) and 'burning it' metabolically and in doing so releasing increasing amounts of Ketone (which is an acid, so causing Ketoacidosis). This rise in acidity, compounded by a drop in urine output, causes a drop in blood Ph, which is incredibly damaging to all parts of the body at a cellular level.

Whilst there is far more involved in looking afte a patient on Intensive Care I hope that this brief explanation shows that 'merely' putting someone on a ventilator has a knock-on to multiple organ groups, all that in turn have a knock-on to other ones.

Teaching someone to operate a ventilator is (comparatively) simple. Teaching someone how to titrate medications, adjust ventilator settings, when to give additional medications to address issues with observed patient 'vitals' etc is not. This is why, as I mentioned earlier in the thread, it can take 12-18 months of additional specialist training before a registered nurse can operate safely as an Intensive Care nurse.

We have to be able to keep the most dependant patients alive without the benefit of calling a doctor for advice all the time. Indeed, generally, the junior doctors will cede to the knowledge of nurses with regards to Intensive Care patients as we're often far more experienced in such s specialist ares than they are (due to the nature of their training/placement program).

- Ventilators are not the sole issue.