Reduced Effective Oxygen Delivery and Ventilation with a Surgical Facemask Placed under Compared to over an Oxygen Mask: A Comparative Study.

OBJECTIVES: Consensus guidelines for perioperative anesthesia management during the COVID-19 pandemic recommend that patients wear a facemask in addition to their oxygen mask or nasal cannulae following tracheal extubation, where this is practical. The effects on effective oxygen delivery and ventilation of a surgical facemask under compared to over an oxygen (O2) mask are unclear. DESIGN: Single-center, comparative pilot study. Setting. Endoscopy procedure room at a major academic hospital. SUBJECTS: Five healthy anesthesiologists. Interventions. Using a carbon dioxide (CO2) sampling line positioned at the lips, the fraction of inspired O2 (FiO2), fraction of expiratory O2 (FeO2), expiratory end-tidal CO2 (EtCO2), and respiratory rate (RR) were measured under the following conditions: (1) a surgical facemask only, (2) a surgical facemask under an O2 mask, (3) an O2 mask only, and (4) a surgical facemask over an O2 mask. Measurements and Main Results. The sampled fractional expired oxygen (FeO2) at the lips was significantly lower when the surgical facemask was under compared to when over the O2 mask (27.9± 1.68 vs. 49.9 ± 6.27, p = 0.001), while there was no significant difference in inspired oxygen (FiO2). The sampled expiratory EtCO2 was significantly higher when the surgical facemask was under the O2 mask compared to when over the O2 mask (28.3 ± 8.5 vs. 23.5 ± 7.6, p = 0.026). The RR was not significantly different when the surgical facemask was under compared to over the O2 mask. CONCLUSIONS: Effective oxygen delivery and ventilation was reduced (lower FeO2 and increased EtCO2) when a surgical facemask was placed under compared to over an O2 mask.

Severe COVID pneumonia and undetectable B cells after vaccination in patients previously treated with rituximab: a case series.

INTRODUCTION: The risk of developing severe COVID-19 illness despite completing vaccination for patients who have previously received immunosuppressive therapy is unclear. CASE PRESENTATION: We present three patients who received rituximab for treatment of autoimmune disorders who subsequently developed severe COVID-19 pneumonia post-vaccination requiring intensive care unit admission and found to have undetectable B cells. DISCUSSION: While there have been concerns about the effectiveness of COVID-19 vaccines in this patient cohort, this is the first case series to report development of severe COVID-19 illness after completing vaccination in those who previously received rituximab. Guidelines for the optimal timing of COVID-19 vaccination in relation to immunosuppressive therapy have been recently published, albeit after many patients in this subpopulation have already been vaccinated. CONCLUSION: This case series brings attention to the limited humoral response to vaccines in patients treated with rituximab, highlights existing guidelines and their limitations, and raises future considerations about the potential benefits to testing vaccine responsiveness.

Teleguidance Technology for Endotracheal Intubation: A Scoping Review.

OBJECTIVES: Teleguidance facilitated intubation has recently reemerged during the coronavirus disease 2019 pandemic as a strategy to provide expert airway management guidance and consultation to practitioners in settings where such expertise is not readily available onsite or in-person. We conducted a scoping review to provide a synthesis of the available literature on teleguidance facilitated intubation. Specifically, we aimed to evaluate the feasibility, safety, and efficacy of teleguidance facilitated intubation given existing technology. DATA SOURCES: A librarian-assisted search was performed using three primary electronic medical databases from January 2000 to November 2020. STUDY SELECTION: Articles that reported outcomes focused on implementing or evaluating the performance of teleguidance facilitated intubation were included. DATA EXTRACTION: Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS: Of 255 citations identified, 17 met eligibility criteria. Studies included prospective investigations and proof of technology reports. These studies were performed in clinical and simulation environments. Five of the prospective investigations that examined time to intubation and intubation success rates. Multiple different commercially available and noncommercial teleconference software systems were used in these studies. CONCLUSIONS: There is a limited body of literature evaluating the feasibility, safety, and efficacy of teleguidance facilitated intubation. Based on the studies available that examined a variety of technologies within simulation and clinical environments, teleguidance facilitated intubation appears to be feasible, safe, and efficacious. Given the exponential growth in the use of telemedicine technology during the coronavirus disease 2019 pandemic and the evidence supporting teleguidance facilitated intubation, there is a need to critically evaluate the most effective mechanisms to integrate and optimize these technologies across diverse practice settings.

Rapid Expansion of the Airway Response Team to Meet the Needs of the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has brought unprecedented numbers of patients with acute respiratory distress to medical centers. Hospital systems require rapid adaptation to respond to the increased demand for airway management while ensuring high quality patient care and provider safety. There is limited literature detailing successful system-level approaches to adapt to the surge of COVID-19 patients requiring airway management. METHODS: A deliberate system-level approach was used to expand a preexisting airway response service. Through a needs analysis (taking into account both existing resources and anticipated demands), we established priorities and solutions for the airway management challenges encountered during the pandemic. RESULTS: During our COVID-19 surge (March 10, 2020, through May 26, 2020), there were 619 airway consults, and the COVID airway response team (CART) performed 341 intubations. Despite a 4-fold increase in intubations during the surge, there was no increase in cardiac arrests or surgical airways and no documented COVID-19 infections among the CART. CONCLUSIONS: Our system-level approach successfully met the sudden escalation in demand in airway management incurred by the COVID-19 surge. The approach that addressed staffing needs prioritized provider protection and enhanced quality and safety monitoring may be adaptable to other institutions.

Nuts and bolts of COVID-19 associated coagulopathy: the essentials for management and treatment.

INTRODUCTION: COVID-19-associated coagulopathy (CAC) is a well-recognized hematologic complication among patients with severe COVID-19 disease, where macro- and micro-thrombosis can lead to multiorgan injury and failure. Major societal guidelines that have published on the management of CAC are based on consensus of expert opinion, with the current evidence available. As a result of limited studies, there are many clinical scenarios that are yet to be addressed, with expert opinion varying on a number of important clinical issues regarding CAC management. METHODS: In this review, we utilize current societal guidelines to provide a framework for practitioners in managing their patients with CAC. We have also provided three clinical scenarios that implement important principles of anticoagulation in patients with COVID-19. CONCLUSION: Overall, decisions should be made on acase by cases basis and based on the providers understanding of each patient's medical history, clinical course and perceived risk.

Inhaled high dose nitric oxide is a safe and effective respiratory treatment in spontaneous breathing hospitalized patients with COVID-19 pneumonia.

BACKGROUND: Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19). METHODS: This is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients. RESULTS: Twenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred. In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4-8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up. CONCLUSIONS: In spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.

An examination of gastrointestinal absorption using the acetaminophen absorption test in critically ill patients with COVID-19: A retrospective cohort study.

OBJECTIVE: Gastrointestinal (GI) dysfunction is prevalent in critically ill patients with coronavirus disease 2019 (COVID-19). The acetaminophen absorption test (AAT) has been previously described as a direct method for assessment of GI function. Our study determines whether the AAT can be used to assess GI function in critically ill COVID-19 patients, compared with traditional measures of GI function. DESIGN: Retrospective observational study of critically ill patients with COVID-19. SETTING: Three intensive care units at a tertiary care academic medical center. PATIENTS: Twenty critically ill patients with COVID-19. INTERVENTIONS: The results of AAT and traditional measures for assessing GI function were collected and compared. MEASUREMENTS AND MAIN RESULTS: Among the study cohort, 55% (11 of 20) of patients had evidence of malabsorption by AAT. Interestingly, all patients with evidence of malabsorption by AAT had clinical evidence of bowel function, as indicated by stool output and low gastric residuals during the prior 24 h. When comparing patients with a detectable acetaminophen level (positive AAT) with those who had undetectable acetaminophen levels (negative AAT), radiologic evidence of ileus was less frequent (20 vs 88%; P = .03), tolerated tube-feed rates were higher (40 vs 10 ml/h; P =.01), and there was a trend toward lower gastric residual volumes (45 vs 830 ml; P =.11). CONCLUSION: Malabsorption can occur in critically ill patients with COVID-19 despite commonly used clinical indicators of tube-feeding tolerance. The AAT provides a simple, rapid, and cost-effective mechanism by which enteral function can be efficiently assessed in COVID-19 patients.

An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19.

PURPOSE: Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with critically ill, mechanically ventilated patients without COVID-19. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center. METHODS: A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated. RESULTS: Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, patients requiring more than 3 agents were of younger age, had an increased body mass index, had increased serum ferritin and lactate dehydrogenase concentrations, had a lower Pao2:Fio2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade. CONCLUSION: Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.

Biplane Imaging Using Portable Ultrasound Devices for Vascular Access.

The use of ultrasound guidance for the placement of difficult IVs, arterial lines, and central venous access has become the standard of care. While imaging quality has improved over the last two decades, the lack of affordability, availability, and training have been major limitations in its routine clinical use. We detail the first reported use of biplane imaging using a portable ultrasound probe for difficult vascular access to increase first past success, efficiency, safety, and sterility during the coronavirus disease 2019 (COVID-19) pandemic.

Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations.

Critically ill patients with COVID-19 are at increased risk for thrombotic complications which has led to an intense debate surrounding their anticoagulation management. In the absence of data from randomized controlled clinical trials, a number of consensus guidelines and recommendations have been published to facilitate clinical decision-making on this issue. However, substantive differences exist between these guidelines which can be difficult for clinicians. This review briefly summarizes the major societal guidelines and compares their similarities and differences. A common theme in all of the recommendations is to take an individualized approach to patient management and a call for prospective randomized clinical trials to address important anticoagulation issues in this population.

Multisystem effects of COVID-19: a concise review for practitioners.

While COVID-19 has primarily been characterized by the respiratory impact of viral pneumonia, it affects every organ system and carries a high consequent risk of death in critically ill patients. Higher sequential organ failure assessment (SOFA) scores have been associated with increased mortality in patients critically ill patients with COVID-19. It is important that clinicians managing critically ill COVID-19 patients be aware of the multisystem impact of the disease so that care can be focused on the prevention of end-organ injuries to potentially improve clinical outcomes. We review the multisystem complications of COVID-19 and associated treatment strategies to improve the care of critically ill COVID-19 patients.

High Concentrations of Nitric Oxide Inhalation Therapy in Pregnant Patients With Severe Coronavirus Disease 2019 (COVID-19).

BACKGROUND: Rescue therapies to treat or prevent progression of coronavirus disease 2019 (COVID-19) hypoxic respiratory failure in pregnant patients are lacking. METHOD: To treat pregnant patients meeting criteria for severe or critical COVID-19 with high-dose (160-200 ppm) nitric oxide by mask twice daily and report on their clinical response. EXPERIENCE: Six pregnant patients were admitted with severe or critical COVID-19 at Massachusetts General Hospital from April to June 2020 and received inhalational nitric oxide therapy. All patients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A total of 39 treatments was administered. An improvement in cardiopulmonary function was observed after commencing nitric oxide gas, as evidenced by an increase in systemic oxygenation in each administration session among those with evidence of baseline hypoxemia and reduction of tachypnea in all patients in each session. Three patients delivered a total of four neonates during hospitalization. At 28-day follow-up, all three patients were home and their newborns were in good condition. Three of the six patients remain pregnant after hospital discharge. Five patients had two negative test results on nasopharyngeal swab for SARS-CoV-2 within 28 days from admission. CONCLUSION: Nitric oxide at 160-200 ppm is easy to use, appears to be well tolerated, and might be of benefit in pregnant patients with COVID-19 with hypoxic respiratory failure.

Transthoracic Echocardiography in Prone Patients With Acute Respiratory Distress Syndrome: A Feasibility Study.

OBJECTIVES: Patients with acute respiratory distress syndrome are at risk for developing cardiac dysfunction which is independently associated with worse outcomes. Transthoracic echocardiography is an ideal imaging modality for goal-directed assessment and optimization of cardiac function and volume status. Prone positioning, while demonstrated to improve oxygenation, offload the right ventricle, and reduce short-term mortality in acute respiratory distress syndrome, has previously precluded transthoracic echocardiography on these patients. The purpose of this study was to assess the ability to perform focused transthoracic echocardiography examinations on acute respiratory distress syndrome patients in the prone position. DESIGN: We performed a cross-sectional study of critically ill patients hospitalized for acute respiratory distress syndrome due to coronavirus disease 2019. SETTING: This study was conducted in medical and surgical intensive units in a tertiary hospital. PATIENTS: We examined 27 mechanically ventilated and prone patients with acute respiratory distress syndrome due to coronavirus disease 2019. Participants were examined at the time of enrollment in an ongoing clinical trial (NCT04306393), and no patients were excluded from echocardiographic analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We were able to perform transthoracic echocardiography and obtain satisfactory images for quantitative assessment of right ventricular function in 24 out of 27 (88.9%) and left ventricular function in 26 out of 27 (96.3%) of patients in the prone position, including many who were obese and on high levels of positive end-expiratory pressure (≥ 15 cm H2O). CONCLUSIONS: Transthoracic echocardiography can be performed at the prone patient's bedside by critical care intensivists. These findings encourage the use of focused transthoracic echocardiography for goal-directed cardiac assessment in acute respiratory distress syndrome patients undergoing prone positioning.

Ultrasound Teleguidance to Reduce Healthcare Worker Exposure to Coronavirus Disease 2019.

The global spread of coronavirus disease 2019 has accelerated the adoption of technologies that facilitate patient care while reducing viral spread. We illustrate a proof of concept application of teleguidance to ultrasound-guided bedside procedures as an example of an innovative solution that has been used at our institution to maximize patient and provider safety.

In-hospital airway management of COVID-19 patients.

Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.