Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS

INTRODUCTION: With the COVID pandemic, and recently updated practice guidelines for neuromuscular infusion (NMBI) use during ARDS, the practices/perceptions of ICU physicians regarding NMBI use during ARDS may not be evidence-based. METHODS: We developed, tested, and electronicallyadministered a questionnaire (9 questions/70 subquestions) to medical and surgical ICU fellow and attending physicians at 3 geographically-diverse U.S. health systems (U Arizona, U Chicago, Mass General Brigham). The IRB-approved questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2 < 150) with critical hypoxemia where dyssynchrony causes were addressed and PEEP optimized. Weekly reminders were sent twice. RESULTS: Respondents [173/342(50.5%)] primarily worked as an attending 117(75%) in a medical ICU 94(60%) for 12±8 weeks/year. COVID+ ARDS patients were twice as likely to receive a NMBI (56±37 vs. 28±19%;p< 0.01). Respondents somewhat/strongly agreed a NMBI: should be reserved until after a trial of deep sedation 142 (82%) or proning 59 (34%), be dose-titrated based on trainof- four monitoring 107(62%);and effectively reduced dyssynchrony 149(86%), plateau pressure 106(62%) and barotrauma 102(60%). Few respondents [23(18%)] somewhat/strongly agreed a NMBI should be initiated at ARDS onset 20(12%) or administered at a fixed-dose 12(7%). Only 2/14 potential NMBI risks were frequently reported to be of high/very high concern: prolonged muscle weakness during steroids 135(79%) and paralysis awareness due to inadequate sedation 114(67%). Only absence of dyssynchrony 146(87%) was frequently reported to be a very/extremely important NMBI titration target. Train-of-four 78(46%) and BIS 39(23%) monitoring and plateau pressure 67(40%) or PaO2:FiO2 64(38%) evaluation were deemed less important. Absence of dysschrony 93(56%) and use ≥48 hours 87(53%) were preferred NMBI stopping criteria. For COVID+ patients, few felt reduced self-extubation and COVID aerosolization during reintubation 16(9%) or reduced ventilator adjustments 7(5%) were very/extremely important reasons for NMBI use. CONCLUSIONS: Most physicians agree NMBI infusions in ARDS should be reserved until after trials of deep sedation. Paralysis awareness and prolonged muscle weakness are the greatest NMBI use concerns. Unique considerations in COVID+ ARDS patients exist.

A telephonic cardiology advice line was effective during the COVID-19 pandemic in both reassuring patients and in ensuring patients received optimal urgent care

A decrease in patients accessing health care was documented during the first COVID-19 surge. We established a 24/7 cardiology telephone advice service during the first surge, this was provided by an experienced cardiology nurse based in a nurse-led cardiac assessment unit. Various options were available on the basis of the telephone consultation. We particularly wanted to see the outcomes of reassurance of patients (to see if the approach was safe) and the outcomes of patients who were directed to emergency departments (to see if this identified patients with significant cardiological and medical problems who may not otherwise have accessed healthcare). We reviewed the progress of the first 999 patients who used the telephonic service for which we had 90 day follow-up data. 141 patients were initially reassured by the nurse at the telephone call. Of these, 55 patients had no further engagement with healthcare providers in the subsequent 90 days. 7 were followed-up within the cardiac rehabilitation program that they were already participating in. 21 were referred to cardiology by their GP but all subsequently had normal assessment and/or investigation. 30 attended an emergency department of whom 22 were discharged directly from the ED;the other 8 patients were admitted to hospital which included 2 patients with non-cardiac chest pain and 2 with exacerbations of known heart failure. 28 patients recontacted the telephonic service during the 90 days and had subsequent face-to-face assessment. There was one death amongst the 141 patients, from a known malignancy. 161 patients were advised to attend an emergency department following telephonic evaluation of whom 50 did not attend. 84 patients were discharged home following assessment in the emergency department of whom 18 were discussed or referred to cardiology for outpatient assessment. 20 patients were admitted under cardiology (8 non-STEMI, 1 complete heart block, 1 profound bradycardia, 1 atrial fibrillation, 1 congestive cardiac failure, 1 critical aortic stenosis, 1 chemotherapy associated cardiotoxicity, 4 no significant cardiac issue found). Nine patients were admitted to non-cardiac wards. We believe that nurse-led telephonic triage can be effective in the management of patients in the community with established cardiac disease or with potential cardiac symptoms. We intend to further develop the service we established during the first surge of the COIVD-19 pandemic.

COVID-19 and compassionate communities: Renewed opportunities for connection

Background and aims: Compassionate Neighbours is a well-established compassionate communities movement initiated through a series of hospices in the south-east of the United Kingdom. When the Covid-19 pandemic hit, it brought death and dying into the living rooms of the nation and new requirements to drastically alter patterns of social contact. For many organisations, volunteering was immediately halted and perceived as being too risky. But what was also being thrust onto the front pages was people's wish to connect, to take local action and support those vulnerable on their street. The Compassionate Neighbours movement did not step back during Covid-19 and in fact grew in numbers of volunteers and connections. This presentation will describe the experiences of one Compassionate Neighbours hub in south-east London and how Covid-19 has altered the landscape for connections at the end of life. Approach taken: - Rapid reassessment of risk which led to routine volunteering being superseded by new flexible, responsive, and safe roles. - Overcoming barriers such as the need for face to face training, identification badges. - New models of connecting such as 'furlongteering' (short, time-limited volunteering options), virtual and telephone communication, deliveries, and practical support for vulnerable. - Early integration with local groups such as the grassroots mutual aid organisations. - Capitalising on the groundswell of interest in volunteering to grow numbers of Compassionate Neighbours. - Bringing a compassionate and experienced response to the fearful narrative on death and dying. Results: Referral numbers for volunteer support peaked during this time, with 2.6 times the number of referrals for the same quarter in 2019 (32 vs 84 referrals per quarter).