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4.
J Intensive Care Med ; 37(2): 240-247, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1463146

ABSTRACT

INTRODUCTION: Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. STUDY DESIGN AND METHODS: A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. RESULTS: 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). INTERPRETATION: This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.


Subject(s)
Analgesia , COVID-19 , Humans , Registries , Retrospective Studies , SARS-CoV-2 , Tracheostomy
6.
Postgrad Med J ; 2021 May 26.
Article in English | MEDLINE | ID: covidwho-1247396

ABSTRACT

COVID-19 continues to be a major source of global morbidity and mortality. It abruptly stressed healthcare systems early in 2020 and the pressures continue. Devastating hardships have been endured by individuals, families and communities; the losses will be felt for years to come. As healthcare professionals and organisations stepped up to respond to the overwhelming number of cases, it is understandable that the focus has been primarily on coping with the quantity of the demand. During a pandemic, it is not surprising that few papers have drawn attention to the quality of the care delivered to those afflicted with illness. Despite the challenges, clinicians caring for patients with COVID-19 have risen to the occasion. This manuscript highlights aspirational examples from the published literature of thoughtful and superb care of patients with COVID-19 using an established framework for clinical excellence (formulated by the Miller-Coulson Academy of Clinical Excellence).

7.
Chest ; 159(5): 1729-1731, 2021 05.
Article in English | MEDLINE | ID: covidwho-1103776
8.
Otolaryngol Head Neck Surg ; 164(6): 1136-1147, 2021 06.
Article in English | MEDLINE | ID: covidwho-901656

ABSTRACT

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.


Subject(s)
COVID-19/prevention & control , Infection Control , Internationality , Perioperative Care , Tracheostomy , COVID-19/epidemiology , COVID-19/transmission , Clinical Protocols , Humans , Practice Patterns, Physicians'
9.
J Immunother Cancer ; 8(1)2020 06.
Article in English | MEDLINE | ID: covidwho-607910

ABSTRACT

Immune-related (IR)-pneumonitis is a rare and potentially fatal toxicity of anti-PD(L)1 immunotherapy. Expert guidelines for the diagnosis and management of IR-pneumonitis include multidisciplinary input from medical oncology, pulmonary medicine, infectious disease, and radiology specialists. Severe acute respiratory syndrome coronavirus 2 is a recently recognized respiratory virus that is responsible for causing the COVID-19 global pandemic. Symptoms and imaging findings from IR-pneumonitis and COVID-19 pneumonia can be similar, and early COVID-19 viral testing may yield false negative results, complicating the diagnosis and management of both entities. Herein, we present a set of multidisciplinary consensus recommendations for the diagnosis and management of IR-pneumonitis in the setting of COVID-19 including: (1) isolation procedures, (2) recommended imaging and interpretation, (3) adaptations to invasive testing, (4) adaptations to the management of IR-pneumonitis, (5) immunosuppression for steroid-refractory IR-pneumonitis, and (6) management of suspected concurrent IR-pneumonitis and COVID-19 infection. There is an emerging need for the adaptation of expert guidelines for IR-pneumonitis in the setting of the global COVID-19 pandemic. We propose a multidisciplinary consensus on this topic, in this position paper.


Subject(s)
Antineoplastic Agents, Immunological/adverse effects , Betacoronavirus/immunology , Coronavirus Infections/prevention & control , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Pneumonia/therapy , Practice Guidelines as Topic , B7-H1 Antigen/antagonists & inhibitors , B7-H1 Antigen/immunology , COVID-19 , Consensus , Coronavirus Infections/epidemiology , Coronavirus Infections/transmission , Coronavirus Infections/virology , Humans , Infectious Disease Medicine/standards , Interdisciplinary Communication , Lung/diagnostic imaging , Lung/drug effects , Lung/immunology , Medical Oncology/standards , Neoplasms/drug therapy , Neoplasms/immunology , Pneumonia/chemically induced , Pneumonia/diagnosis , Pneumonia/immunology , Pneumonia, Viral/epidemiology , Pneumonia, Viral/transmission , Pneumonia, Viral/virology , Pulmonary Medicine/standards , Radiology/standards , SARS-CoV-2 , United States/epidemiology
10.
Lancet Respir Med ; 8(7): 717-725, 2020 07.
Article in English | MEDLINE | ID: covidwho-276408

ABSTRACT

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.


Subject(s)
Betacoronavirus , Coronavirus Infections/therapy , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Internationality , Pneumonia, Viral/therapy , Practice Guidelines as Topic , Tracheostomy/methods , COVID-19 , Coronavirus Infections/prevention & control , Critical Care/methods , Humans , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , SARS-CoV-2
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