Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan's Experience

Prone Position in Mechanically Ventilated COVID-19 Patients: A Multicenter Study

Background: The prone position (PP) is increasingly used in mechanically ventilated coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) patients. However, studies investigating the influence of the PP are currently lacking in these patients. This is the first study to investigate the influence of the PP on the oxygenation and decarboxylation in COVID-19 patients. Methods: A prospective bicentric study design was used, and in mechanically ventilated COVID-19 patients, PP was indicated from a partial pressure of oxygen in arterial blood (P_aO2)/fraction of inspired oxygen (F_IO2) ratio of <200. Patients were left prone for 16 h each. Pressure levels, F_IO2, were adjusted to ensure a P_aO2 greater than 60 mmHg. Blood gas analyses were performed before (baseline 0.5 h), during (1/2/5.5/9.5/13 h), and after being in the PP (1 h), the circulatory/ventilation parameters were continuously monitored, and lung compliance (LC) was roughly calculated. Responders were defined compared to the baseline value (P_aO2/F_IO2 ratio increase of ≥15%; partial pressure of carbon dioxide (P_aCO2) decrease of ≥2%). Results: 13 patients were included and 36 PP sessions were conducted. Overall, P_aO2/F_IO2 increased significantly in the PP (p < 0.001). Most P_aO2/F_IO2 responders (29/36 PP sessions, 77%) were identified 9.5 h after turning prone (14% slow responders), while most P_aCO2 responders (15/36 PP sessions, 42%) were identified 13 h after turning prone. A subgroup of patients (interval intubation to PP ≥3 days) showed less P_aO2/F_IO2 responders (16% vs. 77%). An increase in P_aCO2 and minute ventilation in the PP showed a significant negative correlation (p < 0.001). LC (median before the PP = 38 mL/cm H₂O; two patients with LC >80 mL/cm H₂O) showed a significant positive correlation with the 28 day survival of patients (p = 0.01). Conclusion: The PP significantly improves oxygenation in COVID-19 ARDS patients. The data suggest that they also benefit most from an early PP. A decrease in minute ventilation may result in fewer P_aCO2 responders. LC may be a predictive outcome parameter in COVID-19 patients. Trial registration: Retrospectively registered.

Treatment of unexplained coma and hypokinetic-rigid syndrome in a patient with COVID-19

The COVID-19 pandemic has dealt a devastating blow to healthcare systems globally. Approximately 3.2% of patients infected with COVID-19 require invasive ventilation during the course of the illness. Within this population, 25% of patients are affected with neurological manifestations. Among those who are affected by severe neurological manifestations, some may have acute cerebrovascular complications (5%), impaired consciousness (15%) or exhibit skeletal muscle hypokinesis (20%). The cause of the severe cognitive impairment and hypokinesis is unknown at this time. Potential causes include COVID-19 viral encephalopathy, toxic metabolic encephalopathy, post-intensive care unit syndrome and cerebrovascular pathology. We present a case of a 60 year old patient who sustained a prolonged hospitalization with COVID-19, had a cerebrovascular event and developed a persistent unexplained encephalopathy along with a hypokinetic state. He was treated successfully with modafinil and carbidopa/levodopa showing clinical improvement within 3-7 days and ultimately was able to successfully discharge home.

A Practical Guide for Anesthesia Providers on the Management of Coronavirus Disease 2019 Patients in the Acute Care Hospital

The coronavirus disease 2019 (COVID-19) pandemic has infected millions of individuals and posed unprecedented challenges to health care systems. Acute care hospitals have been forced to expand hospital and intensive care capacity and deal with shortages in personal protective equipment. This guide will review 2 areas where the anesthesiologists will be caring for COVID-19 patients: the operating room and on airway teams. General principles for COVID-19 preparation and hospital procedures will be reviewed to serve as a resource for anesthesia departments to manage COVID-19 or future pandemics.

Healthcare workers in Singapore infected with COVID-19: 23 January-17 April 2020

OBJECTIVE

To describe the characteristics of healthcare workers (HCWs) infected with COVID-19 and to examine their sources of exposure.

METHODS

A descriptive cross-sectional study using data extracted from the centralized disease notification system comprising individuals confirmed with COVID-19 in Singapore between 23 January and 17 April 2020. Occupation of HCWs was categorized into six categories. Their job nature was classified into "frontline" or "back-end" based on the frequency of direct patient contact, and source of exposure was classified as family/household, social interaction or workplace. Chi-square and median tests were used to identify differences between categorical groups and sample medians, respectively.

RESULTS

A total of 88 (1.7%) HCWs were identified from 5,050 cases. Their median age was 35 years. Chinese and Indians constituted 42.0% and 31.8%, respectively, and 43.2% were foreigners. The majority (63.6%) was serving at frontlines handling patient-facing duties, 15.9% were doctors, 11.4% were nurses and 44.3% were ancillary staff. About 81.8% acquired the infection locally, of which 40.3% did not have a clearly identifiable source of exposure. Exposure from the family/household was most common (27.8%), followed by workplace (16.7%) and social interaction (15.3%). All HCWs were discharged well with no mortality; three (3.4%) were ever admitted to intensive care unit and required increased care.

CONCLUSION

Healthcare workers accounted for a small proportion of COVID-19 cases in Singapore with favourable outcomes. The possibility of transmission resulting from family/household exposure and social interactions highlights the need to maintain strict vigilance and precautionary measures at all times beyond the workplace.

Impact of liver enzymes on SARS-CoV-2 infection and the severity of clinical course of COVID-19

BACKGROUND AND AIM

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the current pandemic, can have multi-organ impact. Recent studies show that liver injury could be a manifestation of the disease, and that liver disease could also be related to a worse prognosis. Our aim was to compare the characteristics of patients with severe coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 who required intubation versus stable hospitalized patients to identify the early biochemical predictive factors of a severe course of COVID-19 and subsequent requirement for intubation, specifically in Mexican.

METHODS

This was an observational case-control study nested in a cohort study. Complete medical records of patients admitted for confirmed COVID-19 at a tertiary level center in Mexico City were reviewed. Clinical and biochemical data were collected, and the characteristics of patients who required invasive mechanical ventilation (IMV) (cases) were compared with stable hospitalized patients without ventilation (controls).

RESULTS

We evaluated 166 patients with COVID-19 due to SARS-CoV-2 infection; 114 (68.7%) were men, the mean age was 50.6 ± 13.3 years, and 27 (16.3%) required IMV. The comparative analysis between cases and controls showed (respectively) significantly lower blood oxygen saturation (SpO₂) (73.5 ± 12.0% vs. 83.0 ± 6.8%, P < 0.0001) and elevated alanine aminotransferase (ALT) (128 (14-1123) IU/L vs. 33 (8-453) IU/L, P = 0.003), aspartate aminotransferase (AST) (214 (17-1247) vs. 44 (12-498) IU/L, P = 0.001), lactic dehydrogenase (LDH) (764.6 ± 401.9 IU/L vs. 461.0 ± 185.6 IU/L, P = 0.001), and D-dimer (3463 (524-34,227) ng/mL vs. 829 (152-41,923) ng/mL, P = 0.003) concentrations. Patients in the cases group were older (58.6 ± 12.7 years vs. 49.1 ± 12.8 years, P=0.001). Multivariate analysis showed that important factors at admission predicting the requirement for IMV during hospitalization for COVID-19 were AST ≥250 IU/L (odds ratio (OR) = 64.8, 95% confidence interval (CI) 7.5-560.3, P < 0.0001) and D-dimer ≥ 3500 ng/mL (OR = 4.1, 95% CI 1.2-13.7, P=0.02).

CONCLUSIONS

Our study confirms the importance of monitoring liver enzymes in hospitalized patients with COVID-19; seriously ill patients have significantly elevated AST and D-dimer concentrations, which have prognostic implications in the SARS-CoV-2 disease course.

Pre-operative testing and personal protective equipment in the operating room during a pandemic: A survey of Ontario general surgeons

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had major implications for general surgery practice. We sought to characterize general surgeons' perceptions of their surgical practice in Ontario, Canada, regarding operating room precautions to maximize safety during the pandemic.

METHODS

A web-administered cross-sectional survey was sent to general surgeons registered with the College of Physicians and Surgeons of Ontario on May 19, 2020. Surgeons were surveyed regarding their practices in pre-operative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing, use of intra-operative personal protective equipment (PPE) given a patient's COVID-19 status, and management of common general surgical emergencies with COVID-19 patients. Responses were compared between surgeons from high- and low-prevalence public health units (PHUs) in Ontario using chi-square tests.

RESULTS

There were 81 respondents (rate: 81/271, 30%), 48 (59%) of whom were from a PHU in the top quartile of COVID-19 prevalence. Surgeons from low-prevalence PHUs reported pre-procedural COVID-19 testing rates similar to those reported in high-prevalence PHUs for elective (36% versus 55%), urgent (36% versus 54%), and emergent (20% versus 33%) surgeries. Seventy-eight percent of surgeons with COVID-19-negative patients limited trainees in the operating room compared with 96% of surgeons with COVID-19-positive patients. Use of N95 respirators was 17% for surgeons with COVID-19-negative patients, which dramatically increased to 62% for surgeons with patients whose COVID-19 status was unknown.

CONCLUSIONS

These findings support a need for improved understanding of local disease prevalence and risk of COVID-19 transmission to conserve PPE and return surgical trainees to pre-pandemic standards.

COVID-19 and its impact on the cardiovascular system

OBJECTIVES

The clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.

METHODS

We retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention.

RESULTS

Mean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angiography, two underwent percutaneous coronary intervention and one required a permanent pacemaker implantation. 7.0% (n=35) of patients had an inpatient echocardiogram. Acute myocardial injury (OR 2.39, 95% CI 1.31 to 4.40, p=0.005) and history of hypertension (OR 1.88, 95% CI 1.01 to 3.55, p=0.049) approximately doubled the odds of in-hospital mortality in patients admitted with COVID-19 after other variables had been controlled for.

CONCLUSION

Hypertension, pre-existing CVD and acute myocardial injury were associated with increased in-hospital mortality in our cohort of COVID-19 patients. However, only a low number of patients required invasive cardiac intervention.

Developing and Implementing a Dedicated Prone Positioning Team for Mechanically Ventilated ARDS Patients During the COVID-19 Crisis

Background

The spread of the COVID-19 pandemic in China demonstrated at an early stage the high rate of moderate to severe acute respiratory distress syndrome (ARDS) in the patient population. An intervention that has proved beneficial is the use of prone positioning (PP) for mechanically ventilated patients with ARDS. In one institution, PP was practiced in the medical ICU for this population. However, with the dramatically increasing patient load, staff anticipated that greater capacity to provide this treatment to all qualifying patients would be required.

Methods

A group of physical therapists and occupational therapists (PT/OTs) with ICU experience was redeployed from their regular roles to receive training in PP from an experienced medical ICU (MICU) RN. After intensive training, the team was ready to provide PP to patients. As the workload increased, additional PT/OTs were recruited to the team. A coordinating structure comprising attending pulmonologists screened and advised on appropriate patients. A communication and feedback structure was also implemented.

Results

Over a period of seven weeks, the team provided PP to more than 100 patients, with 577 individual interventions in a total of 14 ICUs and one emergency department. There were no major airway or central venous access complications, and only one anterior pressure injury was recorded.

Conclusion

The rapid implementation of an interdisciplinary PP team in a crisis situation is feasible. It can provide a safe and efficient alternative to adding to the workload of an overloaded nursing staff.

Current Recommendations for Airway Management Techniques in COVID-19 Patients without Respiratory Failure Undergoing General Anaesthesia: A Nonsystematic Literature Review

Summary Background

Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged, many articles have been published on airway management for coronavirus disease 2019 (COVID-19) patients. However, there is a lack of clear and concise conceptual framework for working with infected patients without respiratory failure undergoing general anaesthesia compared to noninfected patients. The aim of this article is to review current literature data on new challenges for anaesthesia providers, compare standard airway management techniques protocols with new data, and discuss optimisation potential.

Materials and methods

Literature search was performed in Google Scholar and PubMed databases using these keywords and their combinations: anaesthesia, preoxygenation, airway management, difficult airway, SARS-CoV-2, COVID-19. The following nonsystematic review is based on a comprehensive literature search of available data, wherein 41 articles were chosen for detailed analysis. Summarised and analysed data are presented in the article.

Results

SARS-CoV-2 has unique implications for airway management techniques in patients without respiratory failure undergoing general anesthesia. Main differences with the standard practice include: institutional preparedness, team composition principles, necessary skills, equipment, drugs, intubation and extubation strategies. Failed or difficult intubation is managed with predominance of emergency front of neck access (FONA) due to increased aerosol generation.

Conclusions

Airway management techniques in COVID-19 patients without respiratory failure are more challenging than in noninfected patients undergoing general anaesthesia. Safe, accurate and swift actions avoid unnecessary time delay ensuring the best care for patients, and reduce risk of contamination for staff. Appropriate airway strategy, communication, minimisation of time for aerosol generating procedures and ramped-up position aid to achieve these goals. During the pandemic, updated available literature data may change clinical practice as new evidence emerges.

Collaboration between the Fab and Fc contribute to maximal protection against SARS-CoV-2 following NVX-CoV2373 subunit vaccine with Matrix-M™ vaccination

Recently approved vaccines have already shown remarkable protection in limiting SARS-CoV-2 associated disease. However, immunologic mechanism(s) of protection, as well as how boosting alters immunity to wildtype and newly emerging strains, remain incompletely understood. Here we deeply profiled the humoral immune response in a cohort of non-human primates immunized with a stable recombinant full-length SARS-CoV-2 spike (S) glycoprotein (NVX-CoV2373) at two dose levels, administered as a single or two-dose regimen with a saponin-based adjuvant Matrix-M™. While antigen dose had some effect on Fc-effector profiles, both antigen dose and boosting significantly altered overall titers, neutralization and Fc-effector profiles, driving unique vaccine-induced antibody fingerprints. Combined differences in antibody effector functions and neutralization were strongly associated with distinct levels of protection in the upper and lower respiratory tract, pointing to the presence of combined, but distinct, compartment-specific neutralization and Fc-mechanisms as key determinants of protective immunity against infection. Moreover, NVX-CoV2373 elicited antibodies functionally target emerging SARS-CoV-2 variants, collectively pointing to the critical collaborative role for Fab and Fc in driving maximal protection against SARS-CoV-2. Collectively, the data presented here suggest that a single dose may prevent disease, but that two doses may be essential to block further transmission of SARS-CoV-2 and emerging variants.

Improving Prone Positioning for Severe Acute Respiratory Distress Syndrome during the COVID-19 Pandemic. An Implementation-Mapping Approach

Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe coronavirus disease 2019 (COVID-19). Despite this, most patients with ARDS do not receive this lifesaving therapy.Objectives: To identify determinants of prone-positioning use, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis.Methods: We used an implementation-mapping approach guided by implementation-science frameworks. We conducted semistructured interviews with 30 intensive care unit (ICU) clinicians who staffed 12 ICUs within the Penn Medicine Health System and the University of Michigan Medical Center. We performed thematic analysis using the Consolidated Framework for Implementation Research. We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response.Results: We identified five broad themes of determinants of prone positioning, including knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five Consolidated Framework for Implementation Research domains. The task force developed five specific implementation strategies, including educational outreach, learning collaborative, clinical protocol, prone-positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.Conclusions: We identified five broad themes of determinants of evidence-based use of prone positioning for severe ARDS and several specific strategies to address these themes. These strategies may be feasible for rapid implementation to increase use of prone positioning for severe ARDS with COVID-19.

SARS-CoV-2: An Update on Genomics, Risk Assessment, Potential Therapeutics and Vaccine Development

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a great threat to public health, being a causative pathogen of a deadly coronavirus disease (COVID-19). It has spread to more than 200 countries and infected millions of individuals globally. Although SARS-CoV-2 has structural/genomic similarities with the previously reported SARS-CoV and MERS-CoV, the specific mutations in its genome make it a novel virus. Available therapeutic strategies failed to control this virus. Despite strict standard operating procedures (SOPs), SARS-CoV-2 has spread globally and it is mutating gradually as well. Diligent efforts, special care, and awareness are needed to reduce transmission among susceptible masses particularly elder people, children, and health care workers. In this review, we highlighted the basic genome organization and structure of SARS-CoV-2. Its transmission dynamics, symptoms, and associated risk factors are discussed. This review also presents the latest mutations identified in its genome, the potential therapeutic options being used, and a brief explanation of vaccine development efforts against COVID-19. The effort will not only help readers to understand the deadly SARS-CoV-2 virus but also provide updated information to researchers for their research work.

Pneumoperitoneum in a COVID-19 Patient Due to the Macklin Effect

A 63-year-old male with coronavirus disease 2019 (COVID-19) pneumonia presented to the emergency department, supplementary oxygen is delivered via nasal cannula, and invasive ventilation was not needed; there was significant pneumoperitoneum on radiologic control. After a meticulous examination of the thoracic tomography, there were some linear air collections adjacent to the bronchovascular sheaths, indicative of the Macklin effect, without abdominal alterations, and the patient remained stable; therefore, we did not perform a surgical procedure, and the pneumoperitoneum reabsorbed spontaneously on radiologic control. The pulmonary origin of pneumoperitoneum is unusual and is associated with mechanical ventilation and alveolar leak; the air leak with subsequent dissection into other anatomical spaces is called the Macklin effect. It is essential to have this mechanism in mind because most of these patients respond well to conservative treatment. When studying primary pneumoperitoneum, the cause should be studied carefully to discard visceral perforation, tracheal or esophageal rupture.

Deep metric learning-based image retrieval system for chest radiograph and its clinical applications in COVID-19

In recent years, deep learning-based image analysis methods have been widely applied in computer-aided detection, diagnosis and prognosis, and has shown its value during the public health crisis of the novel coronavirus disease 2019 (COVID-19) pandemic. Chest radiograph (CXR) has been playing a crucial role in COVID-19 patient triaging, diagnosing and monitoring, particularly in the United States. Considering the mixed and unspecific signals in CXR, an image retrieval model of CXR that provides both similar images and associated clinical information can be more clinically meaningful than a direct image diagnostic model. In this work we develop a novel CXR image retrieval model based on deep metric learning. Unlike traditional diagnostic models which aim at learning the direct mapping from images to labels, the proposed model aims at learning the optimized embedding space of images, where images with the same labels and similar contents are pulled together. The proposed model utilizes multi-similarity loss with hard-mining sampling strategy and attention mechanism to learn the optimized embedding space, and provides similar images, the visualizations of disease-related attention maps and useful clinical information to assist clinical decisions. The model is trained and validated on an international multi-site COVID-19 dataset collected from 3 different sources. Experimental results of COVID-19 image retrieval and diagnosis tasks show that the proposed model can serve as a robust solution for CXR analysis and patient management for COVID-19. The model is also tested on its transferability on a different clinical decision support task for COVID-19, where the pre-trained model is applied to extract image features from a new dataset without any further training. The extracted features are then combined with COVID-19 patient's vitals, lab tests and medical histories to predict the possibility of airway intubation in 72 hours, which is strongly associated with patient prognosis, and is crucial for patient care and hospital resource planning. These results demonstrate our deep metric learning based image retrieval model is highly efficient in the CXR retrieval, diagnosis and prognosis, and thus has great clinical value for the treatment and management of COVID-19 patients.

Collaboration between the Fab and Fc contribute to maximal protection against SARS-CoV-2 in nonhuman primates following NVX-CoV2373 subunit vaccine with Matrix-M™ vaccination

Recently approved vaccines have already shown remarkable protection in limiting SARS-CoV-2 associated disease. However, immunologic mechanism(s) of protection, as well as how boosting alters immunity to wildtype and newly emerging strains, remain incompletely understood. Here we deeply profiled the humoral immune response in a cohort of non-human primates immunized with a stable recombinant full-length SARS-CoV-2 spike (S) glycoprotein (NVX-CoV2373) at two dose levels, administered as a single or two-dose regimen with a saponin-based adjuvant Matrix-M™. While antigen dose had some effect on Fc-effector profiles, both antigen dose and boosting significantly altered overall titers, neutralization and Fc-effector profiles, driving unique vaccine-induced antibody fingerprints. Combined differences in antibody effector functions and neutralization were strongly associated with distinct levels of protection in the upper and lower respiratory tract, pointing to the presence of combined, but distinct, compartment-specific neutralization and Fc-mechanisms as key determinants of protective immunity against infection. Moreover, NVX-CoV2373 elicited antibodies functionally target emerging SARS-CoV-2 variants, collectively pointing to the critical collaborative role for Fab and Fc in driving maximal protection against SARS-CoV-2. Collectively, the data presented here suggest that a single dose may prevent disease, but that two doses may be essential to block further transmission of SARS-CoV-2 and emerging variants.

HIGHLIGHTS

NVX-CoV2373 subunit vaccine elicits receptor blocking, virus neutralizing antibodies, and Fc-effector functional antibodies.The vaccine protects against respiratory tract infection and virus shedding in non-human primates (NHPs).Both neutralizing and Fc-effector functions contribute to protection, potentially through different mechanisms in the upper and lower respiratory tract.Both macaque and human vaccine-induced antibodies exhibit altered Fc-receptor binding to emerging mutants.

Six artificial intelligence paradigms for tissue characterisation and classification of non-COVID-19 pneumonia against COVID-19 pneumonia in computed tomography lungs

Background

COVID-19 pandemic has currently no vaccines. Thus, the only feasible solution for prevention relies on the detection of COVID-19-positive cases through quick and accurate testing. Since artificial intelligence (AI) offers the powerful mechanism to automatically extract the tissue features and characterise the disease, we therefore hypothesise that AI-based strategies can provide quick detection and classification, especially for radiological computed tomography (CT) lung scans.

Methodology

Six models, two traditional machine learning (ML)-based (k-NN and RF), two transfer learning (TL)-based (VGG19 and InceptionV3), and the last two were our custom-designed deep learning (DL) models (CNN and iCNN), were developed for classification between COVID pneumonia (CoP) and non-COVID pneumonia (NCoP). K10 cross-validation (90% training: 10% testing) protocol on an Italian cohort of 100 CoP and 30 NCoP patients was used for performance evaluation and bispectrum analysis for CT lung characterisation.

Results

Using K10 protocol, our results showed the accuracy in the order of DL > TL > ML, ranging the six accuracies for k-NN, RF, VGG19, IV3, CNN, iCNN as 74.58 ± 2.44%, 96.84 ± 2.6, 94.84 ± 2.85%, 99.53 ± 0.75%, 99.53 ± 1.05%, and 99.69 ± 0.66%, respectively. The corresponding AUCs were 0.74, 0.94, 0.96, 0.99, 0.99, and 0.99 (p-values < 0.0001), respectively. Our Bispectrum-based characterisation system suggested CoP can be separated against NCoP using AI models. COVID risk severity stratification also showed a high correlation of 0.7270 (p < 0.0001) with clinical scores such as ground-glass opacities (GGO), further validating our AI models.

Conclusions

We prove our hypothesis by demonstrating that all the six AI models successfully classified CoP against NCoP due to the strong presence of contrasting features such as ground-glass opacities (GGO), consolidations, and pleural effusion in CoP patients. Further, our online system takes < 2 s for inference.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11548-021-02317-0.

Protecting the emergency physician workforce during the coronavirus disease 2019 pandemic through precision scheduling at an academic tertiary care trauma center

The coronavirus disease 2019 (COVID-19) pandemic created new emergency physician staffing challenges. Emergency physicians may be taken out of the workforce because of respiratory symptoms or pending severe acute respiratory syndrome coronavirus 2 test results. Vulnerable emergency physician populations with increased risk of serious disease and death from COVID-19 include physicians at older ages; those with chronic medical conditions, including cardiac and pulmonary diseases and immunosuppression; and potentially pregnancy. We present our approach to planning for staffing issues through precision scheduling. We describe the actions taken to protect our vulnerable physicians and maximize our physician coverage. Measures include optimizing workforce; increasing backup call system; adjusting shifts based on patient arrival times, volume, and surge predictions; minimizing exposure to COVID-19 and reduce personal protective equipment use through telemedicine, huddles, and, creating lower risk emergency department care areas; and standardizing intubations to limit exposure.

Orotracheal intubation incorporating aerosol-mitigating strategies by anaesthesiologists, intensivists and emergency physicians: a simulation study

Background

Orotracheal intubation (OTI) can result in aerosolisation leading to an increased risk of infection for healthcare providers, a key concern during the COVID-19 pandemic.

Objective

This study aimed to evaluate the OTI time and success rate of two aerosol-mitigating strategies under direct laryngoscopy and videolaryngoscopy performed by anaesthesiologists, intensive care physicians and emergency physicians who were voluntarily recruited for OTI in an airway simulation model.

Methodology

The outcomes were successful OTI, degree of airway visualisation and time required for OTI. Not using a stylet during OTI reduced the success rate among non-anaesthesiologists and increased the time required for intubation, regardless of the laryngoscopy device used.

Results

Success rates were similar among physicians from different specialties during OTI using videolaryngoscopy with a stylet. The time required for successful OTI by intensive care and emergency physicians using videolaryngoscopy with a stylet was longer compared with anaesthesiologists using the same technique. Videolaryngoscopy increased the time required for OTI among intensive care physicians compared with direct laryngoscopy. The aerosol-mitigating strategy under direct laryngoscopy with stylet did not increase the time required for intubation, nor did it interfere with OTI success, regardless of the specialty of the performing physician.

Conclusions

The use of a stylet within the endotracheal tube, especially for non-anaesthesiologists, had an impact on OTI success rates and decreased procedural time.

Intubation rate of patients with hypoxia due to COVID-19 treated with awake proning: A meta-analysis

BACKGROUND

Awake prone positioning (PP), or proning, is used to avoid intubations in hypoxic patients with COVID-19, but because of the disease's novelty and constant evolution of treatment strategies, the efficacy of awake PP is unclear. We conducted a meta-analysis of the literature to assess the intubation rate among patients with COVID-19 requiring oxygen or noninvasive ventilatory support who underwent awake PP.

METHODS

We searched PubMed, Embase, and Scopus databases through August 15, 2020 to identify relevant randomized control trials, observational studies, and case series. We performed random-effects meta-analyses for the primary outcome of intubation rate. We used moderator analysis and meta-regressions to assess sources of heterogeneity. We used the standard and modified Newcastle-Ottawa Scales (NOS) to assess studies' quality.

RESULTS

Our search identified 1043 articles. We included 16 studies from the original search and 2 in-press as of October 2020 in our analysis. All were observational studies. Our analysis included 364 patients; mean age was 56.8 (SD 7.12) years, and 68% were men. The intubation rate was 28% (95% CI 20%-38%, I² = 63%). The mortality rate among patients who underwent awake PP was 14% (95% CI 7.4%-24.4%). Potential sources of heterogeneity were study design and setting (practice and geographic).

CONCLUSIONS

Our study demonstrated an intubation rate of 28% among hypoxic patients with COVID-19 who underwent awake PP. Awake PP in COVID-19 is feasible and practical, and more rigorous research is needed to confirm this promising intervention.

Application of Plastic Sheet Barrier and Video Intubating Stylet to Protect Tracheal Intubators During Coronavirus Disease 2019 Pandemic: A Taiwan Experience

Since its outbreak in China, the Coronavirus disease 2019 (COVID-19) pandemic has caused worldwide disaster. Globally, there have been 71,581,532 confirmed cases of COVID-19, including 1,618,374 deaths, reported to World Health Organization (data retrieved on December 16, 2020). Currently, no treatment modalities for COVID-19 (e.g., vaccines or antiviral drugs) with confirmed efficacy and safety are available. Although the possibilities and relevant challenges of some alternatives (e.g., use of stem cells as immunomodulators) have been proposed, the personal protective equipment is still the only way to protect and lower infection rates of COVID-19 among healthcare workers and airway managers (intubators). In this article, we described the combined use of a plastic sheet as a barrier with the intubating stylet for tracheal intubation in patients needing mechanical ventilation. Although conventional or video-assisted laryngoscopy is more popular and familiar to other groups around the world, we believe that the video-assisted intubating stylet technique is much easier to learn and master. Advantages of the video stylet include the creation of greater working distance between intubator and patient, less airway stimulation, and less pharyngeal space needed for endotracheal tube advancement. All the above features make this technique reliable and superior to other devices, especially when a difficult airway is encountered in COVID scenario. Meanwhile, we proposed the use of a flexible and transparent plastic sheet to serve as a barrier against aerosol and droplet spread during airway management. We demonstrated that the use of a plastic sheet would not interfere or hinder the intubator’s maneuvers during endotracheal intubation. Moreover, we demonstrated that the plastic sheet was effective in preventing the spread of mist and water spray in simulation models with a mannequin. In our experience, we found that this technique most effectively protected the intubator and other operating room personnel from infection during the COVID-19 pandemic.

Pressure Injury Prevention in COVID-19 Patients With Acute Respiratory Distress Syndrome

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12–16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.

[Risk stratification nomogram for COVID-19 patients with interstitial pneumonia in the emergency department : A retrospective multicenter study]

Hintergrund

Es gibt zurzeit noch keine zuverlässige Methode zur Früherkennung von COVID-19-Patienten in der Notaufnahme, deren Krankheitsverlauf sich rapide verschlechtern und zum Tod führen kann.

Ziel

Das Ziel dieser Arbeit ist die Untersuchung prädiktiver Risikofaktoren für die 30-Tage-Mortalität bei COVID-19-Patienten mit interstitieller Pneumonie anhand anamnestischer, klinischer und labortechnischer Parameter und die Entwicklung eines Nomogramms zur Risikostratifizierung in der Notaufnahme.

Methode

In den Notaufnahmen der Krankenhäuser von Meran und Brixen wurde im Zeitraum vom 01. März 2020 bis zum 31. März 2020 eine retrospektive multizentrische Studie an einer Kohorte von 164 Patienten mit COVID-19-Pneumonie durchgeführt. Die Patienten wurde mittels Fluoreszenz-Reverse-Transkriptions-Polymerasekettenreaktion (RT-PCR) positiv auf SARS-CoV‑2 getestet. Anhand der untersuchten Parameter wurde ein Nomogramm zur Risikostratifizierung der 30-Tage-Mortalität von COVID-19-Patienten entwickelt.

Ergebnisse

35 (21,3 %) der 164 COVID-19-Patienten mit interstitieller Pneumonie verstarben innerhalb von 30 Tagen nach Aufnahme in die Notaufnahme. Die multivariate Analysemethode ergab, dass kognitive Veränderungen (OR: 8,330; p = 0,004), Lymphozytopenie (OR: 4,229; p = 0,049), Veränderung der Nierenfunktion (OR: 4,841; p = 0,028), periphere Sauerstoffsättigung < 93 % (OR: 17,871; p = 0,002), Alter > 75 Jahre (OR: 2,925; p = 0,032), erhöhtes C‑reaktives Protein (OR: 6,504; p = 0,005), niedrige Monozytenwerte (OR: 0,504; p = 0,004) und Komorbidität (OR 5,862; p = 0,019) mit der 30-Tage-Mortalität assoziiert waren. Anhand dieser 8 Parameter wurde ein Nomogramm entwickelt, das eine gute Diskriminierung mit einer Fläche unter der ROC-Kurve von 0,937 ergab.

Schlussfolgerung

Die erste Auswertung der in der Notaufnahme erhobenen anamnestischen, klinischen und labortechnischen Daten liefert wichtige prognostische Informationen für die Risikostratifizierung von COVID-19-Patienten in der Notaufnahme und für die Früherkennung von kritischen Verläufen.

Management of patients with severe acute respiratory failure due to SARS-CoV-2 pneumonia with noninvasive ventilatory support outside Intensive Care Unit

BACKGROUND

COVID-19 has high mortality rate mainly stemming from acute respiratory distress leading to respiratory failure (ARF). Aim of the study was to evaluate the management of severe ARF due to COVID-19 pneumonia using noninvasive ventilatory support (NIVS), studying safety and effectiveness of NIVS.

METHODS

This is a retrospective, multicenter study. Primary outcomes were NIVS failure with intubation rate and hospital mortality. Secondary outcomes were hospital stay and factors related to NIVS failure and mortality. These outcomes were compared with patients intubated and admitted to ICU.

RESULTS

One hundred sixty-two patients were hospitalized because of severe respiratory failure (PaO<inf>2</inf>/FiO<inf>2</inf> ratio <250). One hundred thirty-eight patients were admitted to Respiratory Intermediate Care Unit (RICU) for a NIVS trial. One hundred patients were treated successfully with NIVS (74.5%); 38 failed NIVS trial (27.5%). In-hospital mortality was 23.18% in RICU group and 30.55% in ICU group. Patients with NIVS failure were older, had a lower number of lymphocytes, a higher IL-6, lower PaO<inf>2</inf>, PaC O<inf>2</inf>, PaO<inf>2</inf>/FiO<inf>2</inf> ratio, higher respiratory rate (RR) and heart rate at admission and lower PaO2, and PaO<inf>2</inf>/FiO<inf>2</inf> ratio and higher RR after 1-6 hours. Multivariate analysis identified higher age, C-reactive protein as well as RR after 1-6 hours and PaO<inf>2</inf>/FiO<inf>2</inf> ratio after 1-6 hours as an independent predictor mortality.

CONCLUSIONS

NIVS is a safe and effective strategy in the treatment of severe ARF due to COVID-19 related pneumonia, that reduces mortality and length of hospital stay in the carefully selected patients.

An Evolving Clinical Need: Discordant Oxygenation Measurements of Intubated COVID-19 Patients

Since the first appearance of the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) earlier this year, clinicians and researchers alike have been faced with dynamic, daily challenges of recognizing, understanding, and treating the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2. Those who are moderately to severely ill with COVID-19 are likely to develop acute hypoxemic respiratory failure and require administration of supplemental oxygen. Assessing the need to initiate or titrate oxygen therapy is largely dependent on evaluating the patient’s existing blood oxygenation status, either by direct arterial blood sampling or by transcutaneous arterial oxygen saturation monitoring, also referred to as pulse oximetry. While the sampling of arterial blood for measurement of dissolved gases provides a direct measurement, it is technically challenging to obtain, is painful to the patient, and can be time and resource intensive. Pulse oximetry allows for non-invasive, real-time, continuous monitoring of the percent of hemoglobin molecules that are saturated with oxygen, and usually closely predicts the arterial oxygen content. As such, it was particularly concerning when patients with severe COVID-19 requiring endotracheal intubation and mechanical ventilation within one of our intensive care units were observed to have significant discordance between their predicted arterial oxygen content via pulse oximetry and their actual measured oxygen content. We offer these preliminary observations along with our speculative causes as a timely, urgent clinical need. In the setting of a COVID-19 intensive care unit, entering a patient room to obtain a fresh arterial blood gas sample not only takes exponentially longer to do given the time required for donning and doffing of personal protective equipment (PPE), it involves the consumption of already sparce PPE, and it increases the risk of viral exposure to the nurse, physician, or respiratory therapist entering the room to obtain the sample. As such, technology similar to pulse oximetry which can be applied to a patients finger, and then continuously monitored from outside the room is essential in preventing a particularly dangerous situation of unrealized hypoxia in this critically-ill patient population. Additionally, it would appear that conventional two-wavelength pulse oximetry may not accurately predict the arterial oxygen content of blood in these patients. This discordance of oxygenation measurements poses a critical concern in the evaluation and management of the acute hypoxemic respiratory failure seen in patients with COVID-19.

Severe COVID-19 Lung Infection in Older People and Periodontitis

Periodontal bacteria dissemination into the lower respiratory tract may create favorable conditions for severe COVID-19 lung infection. Once lung tissues are colonized, cells that survive persistent bacterial infection can undergo permanent damage and accelerated cellular senescence. Consequently, several morphological and functional features of senescent lung cells facilitate SARS-CoV-2 replication. The higher risk for severe SARS-CoV-2 infection, the virus that causes COVID-19, and death in older patients has generated the question whether basic aging mechanisms could be implicated in such susceptibility. Mounting evidence indicates that cellular senescence, a manifestation of aging at the cellular level, contributes to the development of age-related lung pathologies and facilitates respiratory infections. Apparently, a relationship between life-threatening COVID-19 lung infection and pre-existing periodontal disease seems improbable. However, periodontal pathogens can be inoculated during endotracheal intubation and/or aspirated into the lower respiratory tract. This review focuses on how the dissemination of periodontal bacteria into the lungs could aggravate age-related senescent cell accumulation and facilitate more efficient SARS-CoV-2 cell attachment and replication. We also consider how periodontal bacteria-induced premature senescence could influence the course of COVID-19 lung infection. Finally, we highlight the role of saliva as a reservoir for both pathogenic bacteria and SARS-CoV-2. Therefore, the identification of active severe periodontitis can be an opportune and valid clinical parameter for risk stratification of old patients with COVID-19.

Pragmatic Recommendations for the Management of Acute Respiratory Failure and Mechanical Ventilation in Patients with COVID-19 in Low- and Middle-Income Countries

Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.

A Critical Appraisal of the Effects of Anesthetics on Immune-system Modulation in Critically Ill Patients With COVID-19

Purpose

The aim of the present article was to briefly summarize current knowledge about the immunomodulatory effects of general anesthetics and the possible clinical effects of this immunomodulation in patients with COVID-19.

Methods

The PubMed, Scopus, and Google Scholar databases were comprehensively searched for relevant studies.

Findings

The novel coronavirus causes a wide spectrum of clinical manifestations, with a large absolute number of patients experiencing severe pneumonia and rapid progression to acute respiratory distress syndrome and multiple organ failure. In these patients, the equilibrium of the inflammatory response is a major determinant of survival. The impact of anesthetics on immune-system modulation may vary and includes both pro-inflammatory and anti-inflammatory effects.

Implications

Inhibition of the development of severe inflammation and/or the enhancement of inflammation resolution by anesthetics may limit organ damage and improve outcomes in patients with COVID-19.

Effect of early oxygen therapy and antiviral treatment on disease progression in patients with COVID-19: A retrospective study of medical charts in China

Background

Until now, no antiviral treatment has been proven to be effective for the coronavirus disease 2019 (COVID-19). The timing of oxygen therapy was considered to have a great influence on the symptomatic relief of hypoxemia and seeking medical intervention, especially in situations with insufficient medical resources, but the evidence on the timing of oxygen therapy is limited.

Methods and findings

Medical charts review was carried out to collect the data of hospitalized patients with COVID-19 infection confirmed in Tongji hospital, Wuhan from 30^th December 2019 to 8^th March 2020. In this study, the appropriate timing of oxygen therapy and risk factors associated with severe and fatal illness were identified and the effectiveness of antivirus on disease progression was assessed. Among 1362 patients, the prevalence of hypoxia symptoms was significantly higher in those patients with severe and fatal illness than in those with less severe disease. The onset of hypoxia symptoms was most common in the second to third week after symptom onset, and patients with critical and fatal illness experienced these symptoms earlier than those with mild and severe illness. In multivariable analyses, the risk of death increased significantly when oxygen therapy was started more than 2 days after hypoxia symptoms onset among critical patients (OR, 1.92; 95%CI, 1.20 to 3.10). Compared to the critically ill patients without IFN-a, the patients who were treated with IFN-a had a lower mortality (OR, 0.60; 95%CI, 0.39 to 0.91).

Conclusions

Early initiation of oxygen therapy was associated with lower mortality among critical patients. This study highlighted the importance of early oxygen therapy after the onset of hypoxia symptoms. Our results also lend support to potentially beneficial effects of IFNα on critical illness.

Until now, no antiviral treatment has been proven to be effective for the coronavirus disease 2019 (COVID-19). The timing of oxygen therapy, which has rarely been mentioned in the current literature, has a great influence on the symptomatic relief of hypoxemia and seeking medical intervention, especially in situations with limited medical resources. It is worthwhile to find clues from the exploratory use of oxygen and antiviral drugs in Wuhan at the beginning of the COVID-29 pandemic. Therefore, in this study, a retrospective review was carried out to identify the risk factors associated with a severe and fatal illness, including the use of antivirus and timing of oxygen therapy. The main differences in the clinical features of patients with different severities of COVID-19 were described and the risk factors were explored to expand the current recommendations for high-risk groups. Initiation of oxygen treatment less than 2 days after onset after onset of hypoxia symptoms and the use of IFN-a among critically ill patients were significantly associated with lower risk of COVID-19 mortality. Our study highlighted the importance of early oxygen therapy and lend support to the potentially beneficial effects of IFNα on critical illness.

Correlation between Chest CT Severity Scores and the Clinical Parameters of Adult Patients with COVID-19 Pneumonia

PURPOSE

Our aim is to correlate the clinical condition of patients with COVID-19 infection with the 25-point CT severity score by Chang et al. (devised for assessment of ARDS in patients with SARS in 2005).

MATERIALS AND METHODS

Data of consecutive symptomatic patients who were suspected to have COVID-19 infection and presented to our hospital were collected from March to April 2020. All patients underwent two consecutive RT-PCR tests and had a noncontrast HRCT scan done at presentation. From the original cohort of 1062 patients, 160 patients were excluded leaving a total number of 902 patients.

RESULTS

The mean age was 44.2 ± 11.9 years (85.3% males, 14.7% females). CT severity score was found to be positively correlated with lymphopenia, increased serum CRP, d-dimer, and ferritin levels (p < 0.0001). The oxygen requirements and length of hospital stay were increasing with the increase in scan severity.

CONCLUSION

The 25-point CT severity score correlates well with the COVID-19 clinical severity. Our data suggest that chest CT scoring system can aid in predicting COVID-19 disease outcome and significantly correlates with lab tests and oxygen requirements.

Práticas seguras no manejo de vias aéreas de pacientes con Covid-19: revisión integradora

Introdução: A pandemia causada pelo vírus SARS-CoV-2 no início de 2020 alterou práticas dos profissionais de saúde com a finalidade em atenuar os riscos de contaminação dos trabalhadores da linha de frente de assistência à saúde, principalmente, atividades relacionadas ao manejo de vias aéreas de pacientes com Covid-19. Objetivo: identificar as práticas necessárias para garantir a segurança dos profissionais de saúde no manejo de vias aéreas de pacientes suspeitos ou diagnosticados com Covid-19. Materiais e métodos: revisão integrativa realizada em dez bases de dados relevantes na área da saúde, sendo a amostra composta por 17 pesquisas. As práticas identificadas foram elencadas conforme os quatro procedimentos pontuados pela literatura: intubação endotraqueal, extubação, broncoscopia e traqueostomia. Resultados: as principais recomendações mencionadas foram: intubação endotraqueal: realizada por equipe experiente, treinada, mínima e profissionais de grupos de risco para Covid-19 não devem fazer parte desta equipe; extubação: não utilizar cateter nasal de alto fluxo após o procedimento; broncoscopia: realizar em sala isolada e com pressão negativa; traqueostomia: poderá ser considerada precocemente, mas o risco-benefício deve ser avaliado. Conclusão: as práticas identificadas poderão direcionar o gerenciamento de vias aéreas e nortear a construção de tecnologias assistenciais, educacionais ou gerenciais.

Processes for Trauma Care at Six Level I Trauma Centers During the COVID-19 Pandemic

INTRODUCTION

As the COVID-19 pandemic spread, patient care guidelines were published and elective surgeries postponed. However, trauma admissions are not scheduled and cannot be postponed. There is a paucity of information available on continuing trauma care during the pandemic. The study purpose was to describe multicenter trauma care process changes made during the COVID-19 pandemic.

METHODS

This descriptive survey summarized the response to the COVID-19 pandemic at six Level I trauma centers. The survey was completed in 05/2020. Questions were asked about personal protective equipment, ventilators, intensive care unit (ICU) beds, and negative pressure rooms. Data were summarized as proportions.

RESULTS

The survey took an average of 5 days. Sixty-seven percent reused N-95 respirators; 50% sanitized them with 25% using ultraviolet light. One hospital (17%) had regional resources impacted. Thirty-three percent created ventilator allocation protocols. Most hospitals (83%) designated more beds to the ICU; 50% of hospitals designated an ICU for COVID-19 patients. COVID-19 patients were isolated in negative pressure rooms at all hospitals.

CONCLUSIONS

In response to the COVID-19 pandemic, Level I trauma centers created processes to provide optimal trauma patient care and still protect providers. Other centers can use the processes described to continue care of trauma patients during the COVID-19 pandemic.

COVID-19 and the perioperative neuroscience - A narrative review

Among the several medical specialties, anesthesiologists are probably the most affected ones from the coronavirus disease (COVID-19) pandemic as they are at the frontline. In the present stage of the pandemic, where we are observing community transmission, more people with elective neurologic and neurosurgical problems are likely to be tested positive for this virulent disease. Neuroanesthesiologists play an important role in the perioperative period and in neuroradiology suite. It is imperative to know the best available ways by which health care providers can manage their patients and also necessary steps to prevent the spread of infection, not only amongst themselves but also between patients. A high index of suspicion in such patients may help avoid delay in diagnosis and catastrophic sequelae. An overall knowledge about the disease will help plan the clinical management of neurologic patients, during the perioperative period.

Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19

To prevent transmission of severe acute respiratory syndrome coronavirus 2 to healthcare workers, we must quickly implement workflow modifications in the pediatric intensive care unit (PICU). Our objective was to rapidly train interdisciplinary PICU teams to safely perform endotracheal intubations in children with suspected or confirmed coronavirus disease 2019 using a structured simulation education program.

METHODS

We conducted a quality improvement study in a tertiary referral PICU. After developing stakeholder-driven guidelines for modified intubation in this population, we implemented a structured simulation program to train PICU physicians, nurses, and respiratory therapists. We directly observed PICU teams' adherence to the modified intubation process before and after simulation sessions and compared participants' confidence using the Simulation Effectiveness Tool-Modified (SET-M, Likert scale range 0: do not agree to 2: strongly agree regarding statements of confidence).

RESULTS

Fifty unique PICU staff members participated in 9 simulation sessions. Observed intubation performance improved, with teams executing a mean of 7.3-8.4 out of 9 recommended practices between simulation attempts (P = 0.024). Before undergoing simulation, PICU staff indicated that overall they did not feel prepared to intubate patients with suspected or confirmed SARS-CoV-2 (mean SET-M score 0.9). After the simulation program, PICU staff confidence improved (mean SET-M score increased from 0.9 to 2, P < 0.001).

CONCLUSION

PICU teams' performance and confidence in safely executing a modified endotracheal intubation process for children with suspected or confirmed SARS-CoV-2 infection improved using a rapidly deployed structured simulation education program.

Obesity, malnutrition, and trace element deficiency in the coronavirus disease (COVID-19) pandemic: An overview

The world is currently facing the coronavirus disease (COVID-19) pandemic which places great pressure on health care systems and workers, often presents with severe clinical features, and sometimes requires admission into intensive care units. Derangements in nutritional status, both for obesity and malnutrition, are relevant for the clinical outcome in acute illness. Systemic inflammation, immune system impairment, sarcopenia, and preexisting associated conditions, such as respiratory, cardiovascular, and metabolic diseases related to obesity, could act as crucial factors linking nutritional status and the course and outcome of COVID-19. Nevertheless, vitamins and trace elements play an essential role in modulating immune response and inflammatory status. Overall, evaluation of the patient's nutritional status is not negligible for its implications on susceptibility, course, severity, and responsiveness to therapies, in order to perform a tailored nutritional intervention as an integral part of the treatment of patients with COVID-19. The aim of this study was to review the current data on the relevance of nutritional status, including trace elements and vitamin status, in influencing the course and outcome of the disease 3 mo after the World Health Organization's declaration of COVID-19 as a pandemic.

Timing of Invasive Mechanical Ventilation and Mortality among Patients with Severe COVID-19-associated Acute Respiratory Distress Syndrome

Background

Severe acute respiratory distress syndrome associated with coronavirus disease-2019 (COVID-19) (CARDS) pneumonitis presents a clinical challenge as regards to the timing of intubation and ambiguity of outcome. There is a lack of clear consensus on when to switch patients from trials of noninvasive therapies to invasive mechanical ventilation. We investigated the effect of the timing of intubation from the time of admission on the clinical outcome of CARDS.

Aim and objective

The aim and objective was to analyze the effect of timing of intubation early (within 48 hours of admission to critical care unit) versus delayed (after 48 hours of admission to critical care unit) on mortality in severe CARDS patients.

Materials and methods

A retrospective observational study performed in a 28-bedded COVID-19 intensive care unit of a tertiary care hospital in Pune, India. All patients admitted between April 1, 2020, and October 15, 2020, with confirmed COVID-19 (RT-PCR positive) requiring mechanical ventilation were included in the study.

Results

The primary outcome was in-hospital mortality. Among 2,230 patients that were admitted to the hospital, 525 required critical care (23.5%), invasive mechanical ventilation was needed in 162 patients and 147 (28%) of critical care admission were included in the study cohort after exclusion. Seventy-five patients (51%) were intubated within 48 hours of critical care admission (early group) and 72 (48.9%) were intubated after 48 hours of critical care admission (delayed group). With regards to the total of 147 included patients; male patients were 74.1% with a median age of 59 years (interquartile range, 51-68 years). Diabetes (44.9%) and hypertension (43.5%) were the most common comorbidities. Higher admission acute physiology and chronic health evaluation II scores and lower absolute lymphocyte count were observed in patients intubated within 48 hours. The early intubated group had a mortality of 60% whereas the same was observed as 77.7% in delayed intubation group, and this difference was statistically significant (p = 0.02).

Conclusion

Current study concludes that early intubation is associated with improved survival rates in severe CARDS patients.

How to cite this article

Zirpe KG, Tiwari AM, Gurav SK, Deshmukh AM, Suryawanshi PB, Wankhede PP, et al. Timing of Invasive Mechanical Ventilation and Mortality among Patients with Severe COVID-19-associated Acute Respiratory Distress Syndrome. Indian J Crit Care Med 2021;25(5):493-498.

Socioeconomic inequalities in the spread of coronavirus-19 in the United States: A examination of the emergence of social inequalities

OBJECTIVES

To quantify the contribution variation in socioeconomic status in predicting the distribution of COVID-19 cases and deaths.

METHODS

Analyses used incidence data on daily COVID + case counts from all counties from the initial wave of infections, merged with data from the U.S. census data to measure county-level SES and confounders. Multivariable analyses relied on survival analyses and Poisson regression to examine timing of county-level index cases and of COVID-19 incidence and mortality in infected counties to examine the spread and severity of COVID-19 while adjusting for adjusted for Black race, Hispanic ethnicity, age, gender, and urbanicity. Effect moderation by social distancing parameters was examined.

RESULTS

Results indicate that higher SES was associated with earlier incidence of index cases, but that as social distancing took place inequalities in SES inverted so that growth in incidence was slower in higher SES counties, where case-fatality rates were lower.

CONCLUSIONS

This study is the first to date to show what happens when an opportunistic disease that could affect anyone meets the American system of inequality and is powerfully shaped by it.

Occupational hazards in anaesthesiology during the COVID-19 pandemic

According to the Occupational Safety and Health Administration of the Department of Labor of the United States, the exposure risk for anaesthesiologists working with COVID-19 patients can be classified as high or very high. This is mostly due to fact that the anaesthesiologists work in close contact with patients' airways, and the aerosol-generating nature of some procedures they perform. Fortunately, despite the occupational hazard, the incidence of COVID-19 among anaesthesiologists and intensivists remains relatively low. Current evidence suggests that the majority of SARS-CoV-2 infections in this group were either contracted outside of the work environment or can be attributed to personal protective equipment (PPE) malfunction. This article focuses on different aspects of anaesthesiologists' safety, risks connected with different clinical scenarios and procedures, issues related to testing and screening, as well as modifiable and non-modifiable risk factors for severe illness or from COVID-19. This analysis is accompanied by a review of guidelines dedicated to mitigating said risks. Educating the personnel, introducing appropriate procedures, and proper utilisation of PPE are essential to the safety of all parties involved in hospital care, particularly those with significant exposure risk.

Naturally Occurring Animal Coronaviruses as Models for Studying Highly Pathogenic Human Coronaviral Disease

Coronaviruses (CoVs) comprise a large group of positive stranded RNA viruses that infect a diverse host range including birds and mammals. Infection with CoVs typically presents as mild to severe respiratory or enteric disease, but CoVs have the potential to cause significant morbidity or mortality in highly susceptible age groups. CoVs have exhibited a penchant for jumping species barriers throughout history with devastating effects. The emergence of highly pathogenic or infectious CoVs in humans over the past 20 years, including severe acute respiratory syndrome CoV (SARS-CoV), Middle East respiratory syndrome CoV (MERS-CoV), and most recently severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), underscores the significant threat that CoV spillovers pose to humans. Similar to the emergence of SARS-CoV-2, CoVs have been devastating to commercial animal production over the past century, including infectious bronchitis virus in poultry and bovine CoV, as well as the emergence and reemergence of multiple CoVs in swine including transmissible gastroenteritis virus, porcine epidemic diarrhea virus, and porcine deltacoronavirus. These naturally occurring animal CoV infections provide important examples for understanding CoV disease as many animal CoVs have complex pathogenesis similar to SARS-CoV-2 and can shed light on the ongoing SARS-CoV-2 outbreak. We provide an overview and update regarding selected existing animal CoVs and their primary host species, diseases caused by CoVs, how CoVs jump species, whether these CoVs pose an outbreak risk or risk to humans, and how we can mitigate these risks.

Rapid response air medical evacuation by civilian HEMS crew of critical patients during COVID-19 outbreak – First Fixed Points

The Covid-19 emergency requires a shared plan for the longrange helicopter transfer of patients affected by the virus in order to reduce the overload of intensive care units. To date, there is limited peer reviewed literature on aeromedical transport of patients with highly hazardous communicable diseases, most of it is military, and none deals specifically with patients affected by Covid- 19. To meet this need, we propose reference criteria regarding preflight, in-flight and post-flight patient management and helicopter sanitization.

Effect of Early vs. Delayed or No Intubation on Clinical Outcomes of Patients With COVID-19: An Observational Study

Background: Optimal timing of initiation of invasive mechanical ventilation in patients with acute hypoxemic respiratory failure due to COVID-19 is unknown. Thanks to early flattening of the epidemiological curve, ventilator demand in Greece was kept lower than supply throughout the pandemic, allowing for unbiased comparison of the outcomes of patients undergoing early intubation vs. delayed or no intubation.

Methods: We conducted an observational study including all adult patients with laboratory-confirmed COVID-19 consecutively admitted in Evangelismos Hospital, Athens, Greece between March 11, 2020 and April 15, 2020. Patients subsequently admitted in the intensive care unit (ICU) were categorized into the “early intubation” vs. the “delayed or no intubation” group. The “delayed or no intubation” group included patients receiving non-rebreather mask for equal to or more than 24 h or high-flow nasal oxygen for any period of time or non-invasive mechanical ventilation for any period of time in an attempt to avoid intubation. The remaining intubated patients comprised the “early intubation” group.

Results: During the study period, a total of 101 patients (37% female, median age 65 years) were admitted in the hospital. Fifty-nine patients (58% of the entire cohort) were exclusively hospitalized in general wards with a mortality of 3% and median length of stay of 7 days. Forty-two patients (19% female, median age 65 years) were admitted in the ICU; all with acute hypoxemic respiratory failure. Of those admitted in the ICU, 62% had at least one comorbidity and 14% were never intubated. Early intubation was not associated with higher ICU-mortality (21 vs. 33%), fewer ventilator-free days (3 vs. 2 days) or fewer ICU-free days than delayed or no intubation.

Conclusions: A strategy of early intubation was not associated with worse clinical outcomes compared to delayed or no intubation. Given that early intubation may presumably reduce virus aerosolization, these results may justify further research with a randomized controlled trial.

Reconversion of neurosurgical practice in times of the SARS-CoV-2 pandemic: a narrative review of the literature and guideline implementation in a Mexican neurosurgical referral center

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has forced the modification of surgical practice worldwide. Medical centers have been adapted to provide an efficient arrangement of their economic and human resources. Although neurosurgeons are not in the first line of management and treatment of COVID-19 patients, they take care of patients with neurological pathology and potential severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Here, the authors describe their institutional actions against the pandemic and compare these actions with those in peer-reviewed publications.

METHODS

The authors conducted a search using the MEDLINE, PubMed, and Google Scholar databases from the beginning of the pandemic until July 11, 2020, using the following terms: "Neurosurgery," "COVID-19/SARS-CoV-2," "reconversion/modification," "practice," "academy," and "teaching." Then, they created operational guidelines tailored for their institution to maximize resource efficiency and minimize risk for the healthcare personnel.

RESULTS

According to the reviewed literature, the authors defined the following three changes that have had the greatest impact in neurosurgical practice during the COVID-19 pandemic: 1) changes in clinical practices; 2) changes in the medical care setting, including modifications of perioperative care; and 3) changes in the academic teaching methodology.

CONCLUSIONS

The Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez" is one of the major referral centers for treating highly complex neurosurgical pathologies in Mexico. Its clinical and neurosurgical practices have been modified with the implementation of specific interventions against the spread of COVID-19. These practical and simple actions are remarkably relevant in the context of the pandemic and can be adopted and suited by other healthcare centers according to their available resources to better prepare for the next event.

Early practices in endonasal skull base surgery during the COVID-19 pandemic: a global survey

OBJECTIVE

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, endoscopic endonasal surgery (EES) is feared to be a high-risk procedure for the transmission of coronavirus disease 2019 (COVID-19). Nonetheless, data are lacking regarding the management of EES during the pandemic. The object of this study was to understand current worldwide practices pertaining to EES for skull base/pituitary tumors during the SARS-CoV-2 pandemic and provide a basis for the formulation of guidelines.

METHODS

The authors conducted a web-based survey of skull base surgeons worldwide. Different practices by geographic region and COVID-19 prevalence were analyzed.

RESULTS

One hundred thirty-five unique responses were collected. Regarding the use of personal protective equipment (PPE), North America reported using more powered air-purifying respirators (PAPRs), and Asia and Europe reported using more standard precautions. North America and Europe resorted more to reverse transcriptase-polymerase chain reaction (RT-PCR) for screening asymptomatic patients. High-prevalence countries showed a higher use of PAPRs. The medium-prevalence group reported lower RT-PCR testing for symptomatic cases, and the high-prevalence group used it significantly more in asymptomatic cases.Nineteen respondents reported transmission of COVID-19 to healthcare personnel during EES, with a higher rate of transmission among countries classified as having a medium prevalence of COVID-19. These specific respondents (medium prevalence) also reported a lower use of airborne PPE. In the cases of healthcare transmission, the patient was reportedly asymptomatic 32% of the time.

CONCLUSIONS

This survey gives an overview of EES practices during the SARS-CoV-2 pandemic. Intensified preoperative screening, even in asymptomatic patients, RT-PCR for all symptomatic cases, and an increased use of airborne PPE is associated with decreased reports of COVID-19 transmission during EES.

COVID-19 patients in the operating room: a concise review of existing literature

A novel Coronavirus was identified in late 2019 as the cause of COVID-19 disease which is highly contagious. SARS-CoV-2 is a single-stranded RNA, enveloped virus from the beta Coronavirus family. Intraoperative management of patients with COVID-19 is a high-risk procedure. An international attention has raised to develop recommendations for the management strategies. This review article was designed to synthesize the existing evidence and experience related to intraoperative management of COVID-19. This review provides a summary of clinical guidance and addresses six domains: principles of intraoperative monitoring, airway management and related difficulties, ventilation, type of anesthesia, medications and side effects, and intraoperative fluid management.