Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use

IMPORTANCE

Opioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood.

OBJECTIVE

To characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022.

EXPOSURES

Intraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models.

MAIN OUTCOMES AND MEASURES

The primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated.

RESULTS

The study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects.

CONCLUSIONS AND RELEVANCE

Contrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.

Acute Respiratory Distress Syndrome, Mechanical Ventilation, and Inhalation Injury in Burn Patients

Respiratory failure occurs with some frequency in seriously burned patients, driven by a combination of inflammatory and infection factors. Inhalation injury contributes to respiratory failure in some burn patients via direct mucosal injury and indirect inflammation. In burn patients, respiratory failure leading to acute respiratory distress syndrome, with or without inhalation injury, is effectively managed using principles evolved for non-burn critically ill patients.

Intraoperative Ventilator Management of the Critically Ill Patient

Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.

Delivering Low Tidal Volume With Anesthesia and ICU Ventilators in a Neonatal Lung Model

BACKGROUND

Mechanical ventilation of the neonate requires ventilators than can deliver precise and accurate tidal volume (VT) and PEEP to avoid lung injury. Due to small neonatal VT and the disproportionate effect of endotracheal tube leak in these patients, accomplishing precise and accurate VT delivery is difficult. Whereas neonatal ICU ventilators are validated in this population, thorough studies testing the performance of anesthesia ventilators in delivering small VT in neonates are lacking.

METHODS

Three anesthesia ventilators, Dräger Apollo, GE Avance, and Getinge Flow-i; and 2 ICU ventilators, Medtronic PB980 and Nihon Kohden NKV-550, were tested under volume control mode at VT of 5, 20, 40, and 60 mL. Three combinations of lung compliance and airway resistance were tested using a Servo ASL 5000 lung simulator.

RESULTS

In a scenario without leak, the measured VT was greater than the set VT by > 10% in the Apollo (21.0% [18.8-26.0]); measured VT was less than the set VT by > 10% in the Flow-i (-19% [-20.8 to -18.7]). The Avance, PB980, and NKV-550 presented a volume error < 10% (-9.50% [-10.8 to -4.4], -5.8% [-11.8 to -3.5], and 5.4% [-4.5 to 18.9], respectively). Considering all combinations of set VT, leaks, and respiratory mechanics, none of the anesthesia ventilators were able to deliver a median measured VT within a 10% error. The bias between measured VT and set VT varied widely among ventilators (from 4.27 mL to -10.59 mL). Additionally, in the Apollo ventilator, PEEP was underdelivered with the largest leak value.

CONCLUSIONS

Our results suggest that in comparison with the 2 neonatal ICU ventilators tested, the anesthesia ventilators did not greatly differ in terms of VT delivery in the presence of a gas leak.

An Assessment of Carotid Flow Time Using a Portable Handheld Ultrasound Device: The Ideal Tool for Guiding Intraoperative Fluid Management?

Volume resuscitation is a cornerstone of modern anesthesia care. Finding the right balance to avoid inadequate or excess volume administration is often difficult to clinically discern and can lead to negative consequences. Pulse pressure variation is often intraoperatively used to guide volume resuscitation; however, this requires an invasive arterial line and is generally only applicable to patients who are mechanically ventilated. Unfortunately, without a pulmonary artery catheter or another costly noninvasive device, performing serial measurements of cardiac output is challenging, time-consuming, and often impractical. Furthermore, noninvasive measures such as LVOT VTI require significant technical expertise as well as access to the chest, which may not be practical during and after surgery. Other noninvasive techniques such as bioreactance and esophageal Doppler require the use of costly single-use sensors. Here, we present a case report on the use of corrected carotid flow time (ccFT) from a portable, handheld ultrasound device as a practical, noninvasive, and technically straightforward method to assess fluid responsiveness in the perioperative period, as well as the inpatient and outpatient settings.

A Prospective Observational Study on Short and Long-Term Outcomes of COVID-19 Patients with Acute Hypoxic Respiratory Failure Treated with High-Flow Nasal Cannula

(1) The use of high-flow nasal cannula (HFNC) combined with frequent respiratory monitoring in patients with acute hypoxic respiratory failure due to COVID-19 has been shown to reduce intubation and mechanical ventilation. (2) This prospective, single-center, observational study included consecutive adult patients with COVID-19 pneumonia treated with a high-flow nasal cannula. Hemodynamic parameters, respiratory rate, inspiratory fraction of oxygen (F_iO₂), saturation of oxygen (S_pO₂), and the ratio of oxygen saturation to respiratory rate (ROX) were recorded prior to treatment initiation and every 2 h for 24 h. A 6-month follow-up questionnaire was also conducted. (3) Over the study period, 153 of 187 patients were eligible for HFNC. Of these patients, 80% required intubation and 37% of the intubated patients died in hospital. Male sex (OR = 4.65; 95% CI [1.28; 20.6], p = 0.03) and higher BMI (OR = 2.63; 95% CI [1.14; 6.76], p = 0.03) were associated with an increased risk for new limitations at 6-months after hospital discharge. (4) 20% of patients who received HFNC did not require intubation and were discharged alive from the hospital. Male sex and higher BMI were associated with poor long-term functional outcomes.

Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review

Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.

Critical Care of the Vascular Surgery Patient

Patients that require major vascular surgery suffer from widespread atherosclerosis and have multiple comorbidities that place them at increased risk for postoperative complications and require admission to the intensive care unit (ICU). Postoperative critical care of these patients is focused on hemodynamic optimization, and early identification and management of complications to improve outcomes.

Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management

Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.

Bioavailability of Reduced Coenzyme Q10 (Ubiquinol-10) in Burn Patients

Mitochondrial dysfunction has been implicated in the pathogenesis of inflammation and multi-organ dysfunction in major trauma, including burn injury. Coenzyme Q10 (CoQ10) is a metabolite of the mevalonate pathway and an essential cofactor for the electron transport in the mitochondria. In addition, its reduced form (ubiquinol) functions as an antioxidant. Little is known as to whether oral CoQ10 supplementation effectively increases intracellular CoQ10 levels in humans. To study the bioavailability of CoQ10 supplementation, we conducted a randomized, double-blind, placebo-controlled study of reduced CoQ10 (ubiquinol-10) (1800 mg/day, t.i.d.) in burn patients at a single, tertiary-care hospital. Baseline plasma CoQ10 levels were significantly lower in burn patients than in healthy volunteers, although plasma CoQ10/cholesterol ratio did not differ between the groups. CoQ10 supplementation increased plasma concentrations of total and reduced CoQ10 and total CoQ10 content in peripheral blood mononuclear cells (PBMCs) in burn patients compared with the placebo group. CoQ10 supplementation did not significantly change circulating levels of mitochondrial DNA, inflammatory markers (e.g., interleukins, TNF-α, IFN-γ), or Sequential Organ Failure Assessment (SOFA) scores compared with the placebo group. This study showed that a relatively high dose of reduced CoQ10 supplementation increased the intracellular CoQ10 content in PBMCs as well as plasma concentrations in burn patients.

Portable Handheld Point-of-Care Ultrasound for Detecting Unrecognized Esophageal Intubations

Esophageal intubations are not an uncommon occurrence in prehospital settings, occurring as high as 17%. These "never events" are associated with significant morbidity and mortality especially when unrecognized or when there is delayed recognition. Here, we review the currently available techniques for confirming endotracheal tube intubation and their limitations, and present the case for the application of portable handheld point-of-care ultrasound as an emerging technology for detection of potentially unrecognized esophageal intubations such as during cardiac arrest. We also provide algorithms for confirmation of tracheal intubation.

Severe COVID pneumonia and undetectable B cells after vaccination in patients previously treated with rituximab: a case series

INTRODUCTION

The risk of developing severe COVID-19 illness despite completing vaccination for patients who have previously received immunosuppressive therapy is unclear.

CASE PRESENTATION

We present three patients who received rituximab for treatment of autoimmune disorders who subsequently developed severe COVID-19 pneumonia post-vaccination requiring intensive care unit admission and found to have undetectable B cells.

DISCUSSION

While there have been concerns about the effectiveness of COVID-19 vaccines in this patient cohort, this is the first case series to report development of severe COVID-19 illness after completing vaccination in those who previously received rituximab. Guidelines for the optimal timing of COVID-19 vaccination in relation to immunosuppressive therapy have been recently published, albeit after many patients in this subpopulation have already been vaccinated.

CONCLUSION

This case series brings attention to the limited humoral response to vaccines in patients treated with rituximab, highlights existing guidelines and their limitations, and raises future considerations about the potential benefits to testing vaccine responsiveness.

Reduced Effective Oxygen Delivery and Ventilation with a Surgical Facemask Placed under Compared to over an Oxygen Mask: A Comparative Study

Objectives. Consensus guidelines for perioperative anesthesia management during the COVID-19 pandemic recommend that patients wear a facemask in addition to their oxygen mask or nasal cannulae following tracheal extubation, where this is practical. The effects on effective oxygen delivery and ventilation of a surgical facemask under compared to over an oxygen (O2) mask are unclear. Design. Single-center, comparative pilot study. Setting. Endoscopy procedure room at a major academic hospital. Subjects. Five healthy anesthesiologists. Interventions. Using a carbon dioxide (CO2) sampling line positioned at the lips, the fraction of inspired O2 (FiO2), fraction of expiratory O2 (FeO2), expiratory end-tidal CO2 (EtCO2), and respiratory rate (RR) were measured under the following conditions: (1) a surgical facemask only, (2) a surgical facemask under an O2 mask, (3) an O2 mask only, and (4) a surgical facemask over an O2 mask. Measurements and Main Results. The sampled fractional expired oxygen (FeO2) at the lips was significantly lower when the surgical facemask was under compared to when over the O2 mask (27.9± 1.68 vs. 49.9 ± 6.27, $p=0.001$ ), while there was no significant difference in inspired oxygen (FiO2). The sampled expiratory EtCO2 was significantly higher when the surgical facemask was under the O2 mask compared to when over the O2 mask (28.3 ± 8.5 vs. 23.5 ± 7.6, $p=0.026$ ). The RR was not significantly different when the surgical facemask was under compared to over the O2 mask. Conclusions. Effective oxygen delivery and ventilation was reduced (lower FeO2 and increased EtCO2) when a surgical facemask was placed under compared to over an O2 mask.

Noninvasive respiratory support for COVID-19 patients: when, for whom, and how?

The significant mortality rate and prolonged ventilator days associated with invasive mechanical ventilation (IMV) in patients with severe COVID-19 have incited a debate surrounding the use of noninvasive respiratory support (NIRS) (i.e., HFNC, CPAP, NIV) as a potential treatment strategy. Central to this debate is the role of NIRS in preventing intubation in patients with mild respiratory disease and the potential beneficial effects on both patient outcome and resource utilization. However, there remains valid concern that use of NIRS may prolong time to intubation and lung protective ventilation in patients with more advanced disease, thereby worsening respiratory mechanics via self-inflicted lung injury. In addition, the risk of aerosolization with the use of NIRS has the potential to increase healthcare worker (HCW) exposure to the virus. We review the existing literature with a focus on rationale, patient selection and outcomes associated with the use of NIRS in COVID-19 and prior pandemics, as well as in patients with acute respiratory failure due to different etiologies (i.e., COPD, cardiogenic pulmonary edema, etc.) to understand the potential role of NIRS in COVID-19 patients. Based on this analysis we suggest an algorithm for NIRS in COVID-19 patients which includes indications and contraindications for use, monitoring recommendations, systems-based practices to reduce HCW exposure, and predictors of NIRS failure. We also discuss future research priorities for addressing unanswered questions regarding NIRS use in COVID-19 with the goal of improving patient outcomes.

Teleguidance Technology for Endotracheal Intubation: A Scoping Review

Supplemental Digital Content is available in the text.

OBJECTIVES:

Teleguidance facilitated intubation has recently reemerged during the coronavirus disease 2019 pandemic as a strategy to provide expert airway management guidance and consultation to practitioners in settings where such expertise is not readily available onsite or in-person. We conducted a scoping review to provide a synthesis of the available literature on teleguidance facilitated intubation. Specifically, we aimed to evaluate the feasibility, safety, and efficacy of teleguidance facilitated intubation given existing technology.

DATA SOURCES:

A librarian-assisted search was performed using three primary electronic medical databases from January 2000 to November 2020.

STUDY SELECTION:

Articles that reported outcomes focused on implementing or evaluating the performance of teleguidance facilitated intubation were included.

DATA EXTRACTION:

Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

DATA SYNTHESIS:

Of 255 citations identified, 17 met eligibility criteria. Studies included prospective investigations and proof of technology reports. These studies were performed in clinical and simulation environments. Five of the prospective investigations that examined time to intubation and intubation success rates. Multiple different commercially available and noncommercial teleconference software systems were used in these studies.

CONCLUSIONS:

There is a limited body of literature evaluating the feasibility, safety, and efficacy of teleguidance facilitated intubation. Based on the studies available that examined a variety of technologies within simulation and clinical environments, teleguidance facilitated intubation appears to be feasible, safe, and efficacious. Given the exponential growth in the use of telemedicine technology during the coronavirus disease 2019 pandemic and the evidence supporting teleguidance facilitated intubation, there is a need to critically evaluate the most effective mechanisms to integrate and optimize these technologies across diverse practice settings.

Surgical pulmonary embolectomy on VA-ECMO

Surgical pulmonary embolectomy is a procedure that is often used to rescue patients with massive pulmonary embolism (PE) and circulatory collapse that have failed or may not be ideal candidates for other systemic and endovascular treatment modalities. This procedure typically involves a sternotomy and the use of cardiopulmonary bypass (CPB), which requires full systemic anticoagulation. Here, we report the case of a surgical pulmonary embolectomy performed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) rather than CPB to minimize systemic anticoagulation. The patient had suffered a cardiac arrest due to a saddle PE and required VA-ECMO which was complicated by a concomitant intracranial hemorrhage. The patient tolerated the surgical pulmonary embolectomy performed on VA-ECMO without procedure-related complications, and the ECMO support did not substantially complicate the technical performance of the procedure. In contrast to surgical pulmonary embolectomy performed on CPB, greater attention must be paid to volume status when performing the procedure on VA-ECMO since there is no blood reservoir. This case suggests cardiopulmonary support on ECMO as a viable strategy for surgical embolectomy in patients with unstable PEs in whom thrombolysis or full systemic anticoagulation are contraindicated.

Nuts and bolts of COVID-19 associated coagulopathy: the essentials for management and treatment

INTRODUCTION

COVID-19-associated coagulopathy (CAC) is a well-recognized hematologic complication among patients with severe COVID-19 disease, where macro- and micro-thrombosis can lead to multiorgan injury and failure. Major societal guidelines that have published on the management of CAC are based on consensus of expert opinion, with the current evidence available. As a result of limited studies, there are many clinical scenarios that are yet to be addressed, with expert opinion varying on a number of important clinical issues regarding CAC management.

METHODS

In this review, we utilize current societal guidelines to provide a framework for practitioners in managing their patients with CAC. We have also provided three clinical scenarios that implement important principles of anticoagulation in patients with COVID-19.

CONCLUSION

Overall, decisions should be made on acase by cases basis and based on the providers understanding of each patient's medical history, clinical course and perceived risk.

Inhaled high dose nitric oxide is a safe and effective respiratory treatment in spontaneous breathing hospitalized patients with COVID-19 pneumonia

BACKGROUND

Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19).

METHODS

This is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients.

RESULTS

Twenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred. In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4-8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up.

CONCLUSIONS

In spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.

Biplane Imaging Versus Standard Transverse Single-Plane Imaging for Ultrasound-Guided Peripheral Intravenous Access: A Prospective Controlled Crossover Trial

Obtaining peripheral IV access in critically ill patients is often challenging especially for novice providers. The availability of biplane imaging for ultrasound guided peripheral access has the potential to improve successful venous cannulation compared with standard plane imaging.

Comparison of Published Guidelines for the Diagnosis and the Management of Vaccine-Induced Immune Thrombotic Thrombocytopenia

The development of thrombocytopenia and thrombosis after the administration of the AstraZeneca and Johnson & Johnson/Janssen vaccines has been recently described. This new condition has been called vaccine-induced immune thrombotic thrombocytopenia. The objective of this review is to summarize the clinical characteristics and therapeutic options of vaccine-induced immune thrombotic thrombocytopenia based on available published case series. Furthermore, we provide a comparison of the diagnostic pathway and treatment recommendations provided by six major medical societies.

DATA SOURCES

We searched MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials databases.

STUDY SELECTION

We included case series and case reports on patients who developed vaccine-induced immune thrombotic thrombocytopenia. We also included guidelines for the diagnosis and management of vaccine-induced immune thrombotic thrombocytopenia from major medical societies.

DATA EXTRACTION

We examined baseline risk factors, symptoms, physical signs, laboratory and imaging findings, and treatment in patients with vaccine-induced immune thrombotic thrombocytopenia reported in the case series. We also analyzed the diagnostic and treatment recommendations provided by major societal guidelines on the management of vaccine-induced immune thrombotic thrombocytopenia.

DATA SYNTHESIS

Patients who developed vaccine-induced immune thrombotic thrombocytopenia were more likely to be young women (age 20-50) who were given the AstraZeneca or Johnson & Johnson/Janssen 4-28 days prior to presentation. Patients showed signs, symptoms, and imaging findings consistent with cerebral venous sinus thrombosis and splanchnic thrombosis. Laboratory findings showed thrombocytopenia, low fibrinogen, and elevate d-dimer levels, while positive platelet factor 4 antibodies were always positive. Major societal guidelines recommend avoidance of heparin and platelets. Treatment with nonheparin anticoagulants and IV immunoglobulin is also recommended.

CONCLUSIONS

Vaccine-induced immune thrombotic thrombocytopenia is a rare but highly morbid complication related to the administration of the AstraZeneca and Johnson & Johnson/Janssen vaccines. Clinicians should be prepared for the early identification of patients with suspicious symptoms and prompt treatment should be initiated to avoid catastrophic deterioration. Major societal guidelines provide useful recommendations for the diagnosis and management of patients with vaccine-induced immune thrombotic thrombocytopenia.

Rapid Expansion of the Airway Response Team to Meet the Needs of the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic has brought unprecedented numbers of patients with acute respiratory distress to medical centers. Hospital systems require rapid adaptation to respond to the increased demand for airway management while ensuring high quality patient care and provider safety. There is limited literature detailing successful system-level approaches to adapt to the surge of COVID-19 patients requiring airway management.

METHODS

A deliberate system-level approach was used to expand a preexisting airway response service. Through a needs analysis (taking into account both existing resources and anticipated demands), we established priorities and solutions for the airway management challenges encountered during the pandemic.

RESULTS

During our COVID-19 surge (March 10, 2020, through May 26, 2020), there were 619 airway consults, and the COVID airway response team (CART) performed 341 intubations. Despite a 4-fold increase in intubations during the surge, there was no increase in cardiac arrests or surgical airways and no documented COVID-19 infections among the CART.

CONCLUSIONS

Our system-level approach successfully met the sudden escalation in demand in airway management incurred by the COVID-19 surge. The approach that addressed staffing needs prioritized provider protection and enhanced quality and safety monitoring may be adaptable to other institutions.