A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic.

OBJECTIVE: Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes? METHODS: A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days. RESULTS: Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172). CONCLUSION: A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.

RéSUMé: OBJECTIFS: L'intubation orotrachéale est une procédure de sauvetage couramment réalisée dans l'unité de soins intensifs et le service des urgences dans le cadre de la gestion des voies aériennes d'urgence. Avant la pandémie de COVID-19, notre centre a entrepris une étude prospective d'observation pour caractériser l'intubation d'urgence effectuée dans le service des urgences et les établissements de soins intensifs du plus grand hôpital tertiaire du Manitoba. Au cours de cette étude, une expérience naturelle est apparue lorsqu'un " protocole d'intubation à séquence rapide protégé contre le COVID " standardisé a été mis en œuvre en réponse à la pandémie. L'étude qui en a résulté visait à répondre à la question suivante : chez les patients adultes des urgences soumis à une intubation urgente par les équipes de médecine d'urgence et de médecine de soins critiques, l'utilisation d'un " protocole d'intubation à séquence rapide protégé par COVID " a-t-elle un impact sur la réussite du premier passage ou sur d'autres résultats liés à l'intubation ? MéTHODE: Une étude prospective quasi-expérimentale avant et après a été menée dans un seul centre. Les données ont été recueillies prospectivement sur des intubations émergentes consécutives. Le résultat principal était la différence entre les taux de réussite au premier passage. Les résultats secondaires comprenaient la meilleure vue de Cormack­Lehane modifiée, l'hypoxémie, l'hypotension, l'intubation œsophagienne, les scénarios d'impossibilité d'intubation et d'oxygénation, la réanimation cardio-pulmonaire après l'intubation, les vasopresseurs nécessaires après l'intubation, la mortalité en unité de soins intensifs (USI), la durée de séjour en USI et les jours de ventilation mécanique. RéSULTATS: Des données ont été recueillies sur 630 patients, 416 dans la période pré-protocole et 214 dans la période post-protocole. Les taux de réussite au premier passage dans la période pré-protocole se sont avérés être de 73,1 % (n = 304). Suite à l'introduction du protocole, les taux de réussite au premier passage ont augmenté à 82,2 % (n = 176, p = 0,0105). Il y avait une différence statistiquement significative dans la vue Cormack­Lehane modifiée en faveur du protocole (p = 0,0191). Les taux d'intubation œsophagienne se sont avérés être de 5,1 % avant l'introduction du protocole contre 0,5 % après l'introduction du protocole (p = 0,0172). CONCLUSION: Un « protocole protégé contre la COVID ¼ mis en œuvre par les équipes de médecine d'urgence et de médecine de soins critiques en réponse à la pandémie de COVID-19 a été associé à une augmentation des taux de réussite du premier passage et à une diminution des événements indésirables.

Differential Infectivity of Original and Delta Variants of SARS-CoV-2 in Children Compared to Adults.

Although children of all ages are susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, they have not been implicated as major drivers of transmission thus far. However, it is still unknown if this finding holds true with new variants of concern (VOC), such as Delta (B.1.617.2). This study aimed to examine differences in both viral RNA (as measured by cycle threshold [CT]) and viable-virus levels from children infected with Delta and those infected with original variants (OV). Furthermore, we aimed to compare the pediatric population infection trends to those in adults. We obtained 690 SARS-CoV-2 RT-PCR positive nasopharyngeal swabs from across Manitoba, Canada, which were further screened for mutations characteristic of VOC. Aliquots of sample were then provided for TCID50 (50% tissue culture infective dose) assays to determine infectious titers. Using a variety of statistical analyses we compared CT and infectivity of VOC in different age demographics. Comparing 122 Delta- to 175 OV-positive nasopharyngeal swab samples from children, we found that those infected with Delta are 2.7 times more likely to produce viable SARS-CoV-2 with higher titers (in TCID50 per milliliter), regardless of viral RNA levels. Moreover, comparing the pediatric samples to 130 OV- and 263 Delta-positive samples from adults, we found only that the Delta pediatric culture-positive samples had titers (TCID50 per milliliter) similar to those of culture-positive adult samples. IMPORTANCE These important findings show that children may play a larger role in viral transmission of Delta than for previously circulating SARS-CoV-2 variants. Additionally, they may suggest a mechanism for why Delta has evolved to be the predominant circulating variant.

Predicting Infectious Severe Acute Respiratory Syndrome Coronavirus 2 From Diagnostic Samples.

BACKGROUND: Reverse-transcription polymerase chain reaction (RT-PCR) has become the primary method to diagnose viral diseases, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). RT-PCR detects RNA, not infectious virus; thus, its ability to determine duration of infectivity of patients is limited. Infectivity is a critical determinant in informing public health guidelines/interventions. Our goal was to determine the relationship between E gene SARS-CoV-2 RT-PCR cycle threshold (Ct) values from respiratory samples, symptom onset to test (STT), and infectivity in cell culture. METHODS: In this retrospective cross-sectional study, we took SARS-CoV-2 RT-PCR-confirmed positive samples and determined their ability to infect Vero cell lines. RESULTS: Ninety RT-PCR SARS-CoV-2-positive samples were incubated on Vero cells. Twenty-six samples (28.9%) demonstrated viral growth. Median tissue culture infectious dose/mL was 1780 (interquartile range, 282-8511). There was no growth in samples with a Ct > 24 or STT > 8 days. Multivariate logistic regression using positive viral culture as a binary predictor variable, STT, and Ct demonstrated an odds ratio (OR) for positive viral culture of 0.64 (95% confidence interval [CI], .49-.84; P < .001) for every 1-unit increase in Ct. Area under the receiver operating characteristic curve for Ct vs positive culture was OR, 0.91 (95% CI, .85-.97; P < .001), with 97% specificity obtained at a Ct of > 24. CONCLUSIONS: SARS-CoV-2 Vero cell infectivity was only observed for RT-PCR Ct < 24 and STT < 8 days. Infectivity of patients with Ct > 24 and duration of symptoms > 8 days may be low. This information can inform public health policy and guide clinical, infection control, and occupational health decisions. Further studies of larger size are needed.

Comparaison de l'infectivité du coronavirus du syndrome respiratoire aigu sévère 2 chez les enfants et les adultes.

CONTEXTE: Le rôle des enfants dans la propagation et la transmission communautaire du coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) est encore mal compris. Nous visons à quantifier l'infectivité du SRAS-CoV-2 d'échantillons nasopharyngés provenant d'enfants comparativement à ceux provenant d'adultes. MÉTHODES: Nous avons obtenu des écouvillons nasopharyngés de cas adultes et pédiatriques de la maladie à coronavirus 2019 (COVID-19) ainsi que de leurs contacts qui ont obtenu un résultat positif à la présence du SRAS-CoV-2 lors d'un test de dépistage au Manitoba entre les mois de mars et décembre 2020. Nous avons comparé la croissance virale en culture cellulaire, les valeurs de cycle seuil de test d'amplification en chaîne par polymérase couplé à une transcription inverse (RT-PCR) de l'enveloppe (E) du gène du SRAS-CoV-2 et de la dose infectieuse pour 50 % de la culture tissulaire (DICT50/mL) entre les adultes et les enfants. RÉSULTATS: Parmi les 305 échantillons positifs à la présence du SRAS-CoV-2 validés par RT-PCR, 97 échantillons provenaient d'enfants de 10 ans et moins, 78 échantillons d'enfants de 11­17 ans et 130 échantillons d'adultes (≥ 18 ans). On a observé une croissance virale en culture dans 31 % des échantillons, dont 18 (19 %) échantillons d'enfants de 10 ans et moins, 18 (23 %) d'enfants de 11­17 ans et 57 (44 %) d'adultes (enfants c. adultes, rapport de cotes 0,45; intervalle de confiance [IC] à 95 % 0,28­0,72). Le cycle seuil était de 25,1 (IC à 95 % 17,7­31,3) chez les enfants de 10 ans et moins, 22,2 (IC à 95 % 18,3­29,0) chez les enfants de 11­17 ans et 18,7 (IC à 95 % 17,9­30,4) chez les adultes (p < 0,001). La DICT50/mL médiane était considérablement plus faible chez les enfants de 11­17 ans (316, écart interquartile [EI] 178­2125) que chez les adultes (5620, EI 1171­17 800, p < 0,001). Le cycle seuil était un indicateur exact d'une culture positive chez les enfants et les adultes (aire sous la courbe de la fonction d'efficacité du récepteur, 0,87, IC à 95 % 0,81­0,93 c. 0,89, IC à 95 % 0,83­0,96, p = 0,6). INTERPRÉTATION: Comparés aux adultes, les enfants qui ont obtenu un résultat positif à un test de dépistage du SRAS-CoV-2 à l'aide d'un écouvillon nasopharyngé étaient moins susceptibles de présenter une croissance du virus en culture et obtenaient un cycle seuil plus élevé et une concentration virale moins élevée, indiquant que les enfants ne sont pas les principaux vecteurs de la transmission du SRAS-CoV-2.

Infectivity of severe acute respiratory syndrome coronavirus 2 in children compared with adults: CMAJ

BACKGROUND: The role of children in the transmission and community spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. We aimed to quantify the infectivity of SARSCoV- 2 in nasopharyngeal samples from children compared with adults. METHODS: We obtained nasopharyngeal swabs from adult and pediatric cases of coronavirus disease 2019 (COVID-19) and from their contacts who tested positive for SARS-CoV-2 in Manitoba between March and December 2020. We compared viral growth in cell culture, cycle threshold values from the reverse transcription polymerase chain reaction (RT-PCR) of the SARS-CoV-2 envelope (E) gene and the 50% tissue culture infective dose (TCID50/mL) between adults and children. RESULTS: Among 305 samples positive for SARS-CoV-2 by RT-PCR, 97 samples were from children aged 10 years or younger, 78 were from children aged 11-17 years and 130 were from adults (≥ 18 yr). Viral growth in culture was present in 31% of samples, including 18 (19%) samples from children 10 years or younger, 18 (23%) from children aged 11-17 years and 57 (44%) from adults (children v. adults, odds ratio 0.45, 95% confidence interval [CI] 0.28-0.72). The cycle threshold was 25.1 (95% CI 17.7- 31.3) in children 10 years or younger, 22.2 (95% CI 18.3-29.0) in children aged 11-17 years and 18.7 (95% CI 17.9-30.4) in adults (p < 0.001). The median TCID50/mL was significantly lower in children aged 11-17 years (316, interquartile range [IQR] 178-2125) than adults (5620, IQR 1171 to 17 800, p < 0.001). Cycle threshold was an accurate predictor of positive culture in both children and adults (area under the receiver-operator curve, 0.87, 95% CI 0.81-0.93 v. 0.89, 95% CI 0.83-0.96, p = 0.6). INTERPRETATION: Compared with adults, children with nasopharyngeal swabs that tested positive for SARSCoV- 2 were less likely to grow virus in culture, and had higher cycle thresholds and lower viral concentrations, suggesting that children are not the main drivers of SARS-CoV-2 transmission.

Stability of SARS-CoV-2 on critical personal protective equipment.

The spread of COVID-19 in healthcare settings is concerning, with healthcare workers representing a disproportionately high percentage of confirmed cases. Although SARS-CoV-2 virus has been found to persist on surfaces for a number of days, the extent and duration of fomites as a mode of transmission, particularly in healthcare settings, has not been fully characterized. To shed light on this critical matter, the present study provides the first comprehensive assessment of SARS-CoV-2 stability on experimentally contaminated personal protective equipment (PPE) widely used by healthcare workers and the general public. Persistence of viable virus was monitored over 21 days on eight different materials, including nitrile medical examination gloves, reinforced chemical resistant gloves, N-95 and N-100 particulate respirator masks, Tyvek, plastic, cotton, and stainless steel. Unlike previous reports, viable SARS-CoV-2 in the presence of a soil load persisted for up to 21 days on experimentally inoculated PPE, including materials from filtering facepiece respirators (N-95 and N-100 masks) and a plastic visor. Conversely, when applied to 100% cotton fabric, the virus underwent rapid degradation and became undetectable by TCID50 assay within 24 h. These findings underline the importance of appropriate handling of contaminated PPE during and following use in high-risk settings and provide interesting insight into the potential utility of cotton in limiting COVID-19 transmission.

Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery.

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.