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1.
Anesth Analg ; 133(4): 876-890, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1412364

ABSTRACT

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.


Subject(s)
Airway Management/standards , COVID-19/prevention & control , Health Personnel/standards , Infection Control/standards , Personal Protective Equipment/standards , Societies, Medical/standards , Adult , Advisory Committees/standards , Airway Extubation/methods , Airway Extubation/standards , Airway Management/methods , COVID-19/epidemiology , Humans , Infection Control/methods , Intubation, Intratracheal/methods , Intubation, Intratracheal/standards , Practice Guidelines as Topic/standards
3.
Anaesthesia ; 76(12): 1577-1584, 2021 12.
Article in English | MEDLINE | ID: covidwho-1318625

ABSTRACT

Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.


Subject(s)
Airway Extubation/standards , Environmental Monitoring/standards , Intubation, Intratracheal/standards , Operating Rooms/standards , Particle Size , Supraglottitis/therapy , Airway Extubation/methods , Airway Management/methods , Airway Management/standards , Cough/therapy , Environmental Monitoring/methods , Humans , Intubation, Intratracheal/methods , Operating Rooms/methods , Personal Protective Equipment/standards , Prospective Studies
4.
West J Emerg Med ; 22(3): 678-686, 2021 May 17.
Article in English | MEDLINE | ID: covidwho-1266876

ABSTRACT

INTRODUCTION: The objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation. METHODS: We retrospectively collected data on non-operating room (OR) intubations from February 1-April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient's indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result. RESULTS: We obtained 406 independent procedure notes filed between February 1-April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success. DISCUSSION: An average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.


Subject(s)
COVID-19/therapy , Emergency Service, Hospital/statistics & numerical data , Intubation, Intratracheal/statistics & numerical data , COVID-19/epidemiology , Case-Control Studies , Female , Humans , Intubation, Intratracheal/standards , Laryngoscopy/adverse effects , Laryngoscopy/methods , Male , Quality Improvement , Retrospective Studies , SARS-CoV-2
5.
Emerg Med Australas ; 33(4): 728-733, 2021 08.
Article in English | MEDLINE | ID: covidwho-1255059

ABSTRACT

OBJECTIVE: In response to COVID-19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first-attempt success (FAS) associated with ED intubation. METHODS: An analysis of prospectively collected registry data of all ED intubations over a 3-year period at an Australian Major Trauma Centre. During the first 6 months of the COVID-19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with 'sign-off' for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre-drawn medications. RESULTS: There were 783 patients, 136 in the COVID-19 era and 647 in the pre-COVID-19 comparator group. The rate of hypoxia was higher during the COVID-19 era compared to pre-COVID-19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID-19 vs 22.6% pre-COVID-19, P < 0.001). Other adverse events were similar before and during COVID-19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID-19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). CONCLUSIONS: This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.


Subject(s)
Airway Management/methods , COVID-19/therapy , Emergency Service, Hospital/statistics & numerical data , Intubation, Intratracheal/methods , Intubation, Intratracheal/standards , Adult , Aged , Airway Management/standards , Airway Management/statistics & numerical data , Australia , COVID-19/epidemiology , Female , Humans , Intubation, Intratracheal/adverse effects , Laryngoscopy/adverse effects , Laryngoscopy/methods , Male , Middle Aged , Pandemics , Prospective Studies , Quality Improvement , SARS-CoV-2
7.
Anesth Analg ; 133(4): 876-890, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1133644

ABSTRACT

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.


Subject(s)
Airway Management/standards , COVID-19/prevention & control , Health Personnel/standards , Infection Control/standards , Personal Protective Equipment/standards , Societies, Medical/standards , Adult , Advisory Committees/standards , Airway Extubation/methods , Airway Extubation/standards , Airway Management/methods , COVID-19/epidemiology , Humans , Infection Control/methods , Intubation, Intratracheal/methods , Intubation, Intratracheal/standards , Practice Guidelines as Topic/standards
9.
Emerg Med J ; 38(3): 217-219, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1011009

ABSTRACT

Our ED-intensive care unit has instituted a new protocol meant to maximise the safety of physicians, nurses and respiratory therapists involved with endotracheal intubation of patients known or suspected of being infected with the novel SARS-CoV-2. The level of detail involved with this checklist is a deviation from standard intubation practices and is likely unfamiliar to most emergency physicians. However, the two-person system used in our department removes the cognitive burden such complexity would otherwise demand and minimises the number of participants that would typically be exposed during endotracheal intubation. We share this checklist to demonstrate to other departments how adopting international airway guidelines to a specific institution can be achieved in order to promote healthcare worker safety.


Subject(s)
COVID-19 , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Intubation, Intratracheal/standards , SARS-CoV-2 , Checklist , Emergency Service, Hospital , Humans , New York , Pandemics
12.
Anesthesiology ; 132(6): 1317-1332, 2020 06.
Article in English | MEDLINE | ID: covidwho-944425

ABSTRACT

The COVID-19 outbreak has led to 80,409 diagnosed cases and 3,012 deaths in mainland China based on the data released on March 4, 2020. Approximately 3.2% of patients with COVID-19 required intubation and invasive ventilation at some point in the disease course. Providing best practices regarding intubation and ventilation for an overwhelming number of patients with COVID-19 amid an enhanced risk of cross-infection is a daunting undertaking. The authors presented the experience of caring for the critically ill patients with COVID-19 in Wuhan. It is extremely important to follow strict self-protection precautions. Timely, but not premature, intubation is crucial to counter a progressively enlarging oxygen debt despite high-flow oxygen therapy and bilevel positive airway pressure ventilation. Thorough preparation, satisfactory preoxygenation, modified rapid sequence induction, and rapid intubation using a video laryngoscope are widely used intubation strategies in Wuhan. Lung-protective ventilation, prone position ventilation, and adequate sedation and analgesia are essential components of ventilation management.


Subject(s)
Coronavirus Infections , Disease Transmission, Infectious/prevention & control , Intubation, Intratracheal/standards , Pandemics , Pneumonia, Viral , Respiration, Artificial/standards , COVID-19 , China , Coronavirus Infections/epidemiology , Coronavirus Infections/prevention & control , Coronavirus Infections/transmission , Hospitals/standards , Humans , Pandemics/prevention & control , Patient Selection , Pneumonia, Viral/epidemiology , Pneumonia, Viral/prevention & control , Pneumonia, Viral/transmission
14.
Emerg Med J ; 37(6): 381-383, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-805011

ABSTRACT

A short-cut review of the literature was carried out to examine whether video laryngoscopy (VL) could improve first-pass success and reduce complication rates in ED patients requiring endotracheal intubation, when compared with direct laryngoscopy. Four papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that current evidence suggests VL is likely to improve first-pass success and reduce oesophageal intubation rates, but there is no evidence at present that it improves clinically relevant outcomes. In addition, no difference was found between first-pass success rates in senior/experienced operators, who should use techniques with which they are familiar.


Subject(s)
Intubation, Intratracheal/instrumentation , Intubation, Intratracheal/standards , Laryngoscopy/standards , Video Recording/instrumentation , Adult , Emergency Service, Hospital/organization & administration , Emergency Service, Hospital/trends , Humans , Intubation, Intratracheal/methods , Laryngoscopy/methods , Laryngoscopy/statistics & numerical data , Video Recording/methods , Video Recording/trends
17.
Am J Med Qual ; 35(6): 450-457, 2020 12.
Article in English | MEDLINE | ID: covidwho-719535

ABSTRACT

The COVID-19 pandemic has forced the health care industry to develop dynamic protocols to maximize provider safety as aerosolizing procedures, specifically intubation, increase the risk of contracting SARS-CoV-2. The authors sought to create a quality improvement framework to ensure safe practices for intubating providers, and describe a multidisciplinary model developed at an academic tertiary care facility centered on rapid-cycle improvements and real-time gap analysis to track adherence to COVID-19 intubation safety protocols. The model included an Intubation Safety Checklist, a standardized documentation template for intubations, obtaining real-time feedback, and weekly multidisciplinary team meetings to review data and implement improvements. This study captured 68 intubations in suspected COVID-19 patients and demonstrated high personal protective equipment compliance at the institution, but also identified areas for process improvement. Overall, the authors posit that an interdisciplinary workgroup and the integration of standardized processes can be used to enhance intubation safety among providers during the COVID-19 pandemic.


Subject(s)
Coronavirus Infections/therapy , Interdisciplinary Communication , Intubation, Intratracheal/standards , Management Quality Circles/standards , Pneumonia, Viral/therapy , Quality Improvement/organization & administration , Airway Management/standards , Betacoronavirus , COVID-19 , Cooperative Behavior , Humans , Pandemics , Personal Protective Equipment , SARS-CoV-2
18.
Medwave ; 20(6): e7950, 2020 Jul 02.
Article in Spanish, English | MEDLINE | ID: covidwho-696250

ABSTRACT

The purpose of this article is to review the characteristics of SARS-CoV-2, the clinical-epidemiological aspects of COVID-19, and the implications anesthesiologists when performing aerosol-generating procedures. A search of PubMed/MEDLINE, Scopus, SciELO, and Web of Science databases was performed until April 9, 2020, using the words: "COVID-19 or COVID19 or SARS-CoV-2 and anesthesiology or anesthesia". Forty-eight articles with information on the management of the patient in the perioperative period or the intensive care unit when suspected or confirmed SARS-CoV-2 infection were included. In general, the postponement of elective surgeries for no more than 6 to 8 weeks, depending on the clinical condition of the patients is recommended. In the case of urgent or emergency surgeries, we review the use of personal protection gear, as well as the recommended strategies for carrying out the procedure.


El objetivo de este artículo es revisar las características del SARS-CoV-2, los aspectos clínico-epidemiológicos de COVID-19 y las implicaciones que tienen para los anestesiólogos al realizar procedimientos generadores de aerosoles. Se realizó una búsqueda en las bases de datos PubMed, Scopus, SciELO y Web of Science hasta el 9 de abril de 2020, utilizando las palabras: “COVID-19 or COVID19 or SARS-CoV-2 and anesthesiology or anesthesia”. Se incluyeron 48 artículos con información sobre el manejo del paciente en el perioperatorio o en la unidad de cuidados intensivos ante la sospecha o confirmación de infección por SARS-CoV-2. En general, se recomienda el aplazamiento de las cirugías electivas por no más de seis a ocho semanas, de acuerdo a las condiciones clínicas de los pacientes. En el caso de cirugías de urgencia o emergencia, se revisan tópicos del sistema de protección personal así como las estrategias recomendadas para la realización de los procedimientos.


Subject(s)
Anesthesiology/standards , Betacoronavirus , Coronavirus Infections/complications , Coronavirus Infections/epidemiology , Occupational Diseases/prevention & control , Pneumonia, Viral/complications , Pneumonia, Viral/epidemiology , Aerosols , Anesthesia, Conduction/methods , Anesthesia, Epidural/methods , Anesthesia, General/methods , Anesthesia, Spinal/methods , Anesthesiology/organization & administration , Betacoronavirus/genetics , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/transmission , Elective Surgical Procedures , Humans , Intensive Care Units , Intubation, Intratracheal/methods , Intubation, Intratracheal/standards , Nerve Block/methods , Pandemics , Personal Protective Equipment , Pneumonia, Viral/diagnosis , Pneumonia, Viral/transmission , Respiration, Artificial/methods , Respiration, Artificial/standards , SARS-CoV-2 , Surgical Procedures, Operative , Symptom Assessment/methods
20.
Chin Med Sci J ; 35(2): 114-120, 2020 Jun 30.
Article in English | MEDLINE | ID: covidwho-656608

ABSTRACT

A novel coronavirus that emerged in late 2019 rapidly spread around the world. Most severe cases need endotracheal intubation and mechanical ventilation, and some mild cases may need emergent surgery under general anesthesia. The novel coronavirus was reported to transmit via droplets, contact and natural aerosols from human to human. Therefore, aerosol-producing procedures such as endotracheal intubation and airway suction may put the healthcare providers at high risk of nosocomial infection. Based on recently published articles, this review provides detailed feasible recommendations for primary anesthesiologists on infection prevention in operating room during COVID-19 outbreak.


Subject(s)
Betacoronavirus , Coronavirus Infections/prevention & control , Cross Infection/prevention & control , Disease Outbreaks/prevention & control , Operating Rooms/standards , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Anesthesiologists/standards , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/transmission , Cross Infection/epidemiology , Cross Infection/transmission , Humans , Intubation, Intratracheal/methods , Intubation, Intratracheal/standards , Operating Rooms/methods , Pneumonia, Viral/epidemiology , Pneumonia, Viral/transmission , SARS-CoV-2
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