ABSTRACT
INTRODUCTION: Since the start of the COVID-19 pandemic there has been an evolution of variant strains that have spread throughout the world. As time has passed, clinicians have appreciated that these variants have different symptomology and clinical course. As our understanding of the disease process has progressed, medical management has evolved. Throughout, cancer patients have represented a uniquely at-risk population. We sought to compare the characteristics of critically ill cancer patients with Omicron variant to those infected with the ancestral strain. METHOD(S): Single-center retrospective cohort study analyzed all cancer patients >=18 years of age with current or past (< 2 years) diagnosis of cancer, who were admitted to ICU with COVID-19. The ancestral strain period was defined as March 1 to June 30, 2020, and the Omicron variant period was December 15, 2021 to April 1, 2022. Demographics, clinical and laboratory data of critically ill cancer patients were extracted from electronic health record and an ICU database. RESULT(S): A total of 127 patients were analyzed (38 Omicron and 89 ancestral strain). Median age was similar (67 years Omicron, 65 ancestral) and slightly higher male (47% Omicron, 58% ancestral). There was a higher number of hematologic malignancy (53% Omicron, 43% ancestral). Mechanical ventilation and vasopressors were less commonly used (58% and 53% Omicron, 67% and 71% ancestral), respectively. Prone positioning was utilized less frequently (47% Omicron, 56% ancestral) as was tracheostomy (11% omicron, 34% ancestral). ICU mortality was similar in both groups, (39% vs 37% however, hospital mortality was higher (55% Omicron group, 45% ancestral). CONCLUSION(S): Critically ill cancer patients infected with the Omicron variant may be less likely to undergo tracheostomy however, they are more likely to die during their hospitalization. Even with higher hospital mortality Omicron patients also seemed to be less acutely ill as their requirement for mechanical ventilation, vasopressors and prone positioning was lower. This should be considered as we counsel patients and set expectations about what might happen during a COVID admission to the ICU.
ABSTRACT
Objective: We recently provided a framework, the protected code stroke, for the implementation of safety measures and other key considerations during the coronavirus disease 2019 (COVID-19) pandemic. Herein we provide updates to the framework from the frontlines as the pandemic evolves. Background: Hyperacute assessment and management of patients with stroke is a time-sensitive and high-stakes clinical scenario. In the context of the current COVID-19 pandemic, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery while rapid triage is important for those who may be presenting with neurological symptoms, but have an alternative diagnosis. Design/Methods: Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Feedback from frontline providers implementing the protocol was collected. Results: Features specific to pre-notification and clinical status of the patient were used to define pre-code screening. A focused framework was then developed with regard to a protected code stroke. Feedback was used to generate tips with regards to implementation, team management strategies, and an evolving understanding of infection control strategies during a code stroke. Conclusions: We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for crucial considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice. The protocol has since been endorsed and adopted at many centers globally.
ABSTRACT
Background and Purpose- Hyperacute assessment and management of patients with stroke, termed code stroke, is a time-sensitive and high-stakes clinical scenario. In the context of the current coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those who may be presenting with neurological symptoms but have an alternative diagnosis. Methods- Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Results- A protected code stroke algorithm was developed. Features specific to prenotification and clinical status of the patient were used to define precode screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regard to a protected code stroke. We outline the specifics of personal protective equipment use and considerations thereof including aspects of crisis resource management impacting team role designation and human performance factors during a protected code stroke. Conclusions- We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for key considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice.