The Considerations and Controversies in Using High-Flow Nasal Oxygen with Self-Prone Positioning in SARS-CoV-2 COVID-19 Disease.

Evidence exists for the use of high-flow nasal oxygen (HFNO) in the general critical care population for acute hypoxemic respiratory failure. There is discord between guidelines for hypoxemia management in COVID-19. Both noninvasive management and intubation present risk to patients and staff and potentially overwhelm hospital mechanical ventilator capacity. The use of HFNO has been particularly controversial in the UK, with oxygen infrastructure failure. We discuss our experience of managing COVID-19 with HFNO and awake self-prone positioning. We focus upon the less-usual case of an eighteen-year-old female to illustrate the type of patient where HFNO may be used when perhaps earlier intubation once was. It is important to consider the wider implications of intubation. We have used HFNO as a bridge to intubation or as definitive management. As we await clinical trial evidence, HFNO with self-prone positioning has a role in COVID-19 for certain patients. Response parameters must be set and reviewed, oxygen infrastructure considered, and potential staff droplet exposure minimised.

Organ donation after circulatory death: an update.

There is an ongoing shortfall of organs for donation in the UK and worldwide. Strategies including donation after circulatory death (DCD), living donation and better identification of potential donors are attempting to increase the number of donors and donated organs. The number of DCD donors in the UK increased by 808% from 37 to 336 between 2001 and 2010 and this is continuing to increase. The most common organs donated from DCD donors are the kidneys, but there is increasing experience of liver, lung and pancreas transplantation. The process of DCD varies between different countries and institutions. The outcome of DCD transplantation has been largely encouraging, particularly for kidneys. The increase in DCD has led to an appraisal of issues that may arise during the donation process; these include the Lazarus phenomenon, the dead donor rule, perimortem interventions, public opinion and conflict of interest for clinicians.

Controlled organ donation after cardiac death: potential donors in the emergency department.

BACKGROUND.: The continuing shortfall of organs for transplantation has increased the use of donation after cardiac death (DCD). We hypothesized that some patients who undergo tracheal intubation in the emergency department (ED) and who are assessed for, but not admitted to, critical care might have potential for controlled DCD. METHODS.: We identified all patients who underwent tracheal intubation in the ED between 2004 and 2008 and studied their records to identify those not admitted to an intensive care unit. We reviewed the notes of patients extubated in the ED to ascertain the diagnosis, management, outcome, and potential exclusion criteria for controlled DCD. RESULTS.: One thousand three hundred seventy-four patients had tracheal intubation performed in the ED; 1053 received anesthetic drugs to assist intubation. Three hundred seventy-five patients were not admitted to intensive care unit; 235 died during resuscitation in the ED. Of the 49 patients extubated in the ED to allow terminal care, 26 were older than 70 years and 18 had comorbidities precluding organ donation. Fourteen patients could have been considered for DCD, but in eight, the time from extubation to death exceeded 2 hr. Thus, six patients might have been missed as potential controlled DCD from the ED in this 5-year period. CONCLUSIONS.: Identification of potential donors after cardiac death in the ED with appropriate use of critical care for selected patients may contribute to reducing the shortfall of organs for transplantation, although numbers are likely to be small. This area remains controversial and requires further informed discussion between emergency and critical care doctors and transplant teams.