Assessing whether COVID-19 patients will benefit from critical care, and an objective approach to capacity challenges during a pandemic: An Intensive Care Society clinical guideline.

This national professional society guidance lays out operational and ethical principles for decision-making during a pandemic, in the immediate context of COVID-19 in the early 2020 surge iteration but with potential ongoing relevance. It identifies the different phases of a pandemic and the implications for capacity and mutual aid within a national healthcare system, and introduces a revised CRITCON-PANDEMIC framework for shared operational responsibilities and clinical decision-making. Usual legal and ethical frameworks should continue to apply while capacity and mutual aid are available (CRITCON-PANDEMIC levels 0-3); clinicians should focus on current clinical needs and should not treat patients differently because of anticipated future pressures. In conditions of resource limitation (CRITCON-PANDEMIC 4), a structured and equitable approach is necessary and an objective Decision Support Aid is proposed. In producing this guidance, we emphasise that all patients must be treated with respect and without discrimination, because everyone is of equal value. The guidance has been put together with input from patient and public groups and aims to provide standards that are fair to everyone. We acknowledge that COVID-19 is a new disease with a partial and evolving knowledge base, and aim to provide an objective clinical decision-making framework based on the best available information. It is recognised that a factual assessment of likely benefit may take into account age, frailty and comorbidities, but the guidance emphasises that every assessment must be individualised on a balanced, case by case, basis and may inform clinical judgement but not replace it. The effects of a comorbidity on someone's ability to benefit from critical care should be individually assessed. Measures of frailty should be used with care, and should not disadvantage those with stable disability.

Guidelines for the management of tracheal intubation in critically ill adults.

These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.

Influence of direct and indirect etiology on acute outcome and 6-month functional recovery in acute respiratory distress syndrome.

OBJECTIVE: To assess the possibility that acute respiratory distress syndrome (ARDS) of pulmonary and nonpulmonary origins represent two distinct syndromes. DESIGN: Analysis of data collected prospectively from an inception cohort of 117 patients with ARDS. SETTING: Adult intensive care unit (ICU), university/postgraduate hospital. MEASUREMENTS AND MAIN RESULTS: Differences were sought in mortality and 6-month functional outcome between patients developing ARDS due to pulmonary (group 1) and nonpulmonary (group 2) pathology. Group 1 patients displayed a trend toward increased ICU and in-hospital mortality (42.1% vs. 23.2%, p = .10, and 47.4% vs. 27.9%, p = .11, respectively). No difference was found in ICU length of stay (46.3 +/- 4.9 vs. 39.0 +/- 4.8 days for groups 1 and 2, respectively) nor in duration of positive-pressure ventilation (26.2 +/- 4.3 vs. 20.6 +/- 3.2 days). However, the need for pressure-controlled inverse ratio ventilation was significantly greater in group 1 (16.9 +/- 3.2 vs. 9.1 +/- 1.3 days; p = .033). In survivors, reductions in total lung capacity at 6 months (68.1 +/- 4.6 vs. 61.8 +/- 4.6% predicted for groups 1 and 2, respectively; p = .4), accessible lung volume (74.4 +/- 4.4 vs. 68.9 +/- 4.9% predicted; p = .56), and forced expiratory volume (77.8 +/- 2.9 vs. 80.3 +/- 2.4% predicted; p = .57) did not differ between groups. Gas transfer coefficient was well preserved (84.5 +/- 4.6 vs. 86.6 +/- 4.7% predicted; p = .80). CONCLUSIONS: These data suggest a trend toward higher mortality and ventilatory requirements in ARDS of direct etiology, generating a hypothesis worthy of further exploration.

Acute respiratory distress syndrome caused by pulmonary and extrapulmonary injury: a comparative CT study.

PURPOSE: To determine computed tomographic (CT) differences between acute respiratory distress syndrome (ARDS) due to pulmonary injury (ARDS(p)) and extrapulmonary injury (ARDS(ex)). MATERIALS AND METHODS: CT appearances in 41 patients (27 male, 14 female; mean age, 47.1 years +/- 17.1 [SD]; age range, 17-79 years; those with ARDS(p), n = 16; those with ARDS(ex), n = 25) were categorized as typical or atypical of ARDS by two observers. The extent of individual CT patterns was also quantified. RESULTS: Typical CT appearances were more frequent in ARDS(ex) than ARDS(p) (18 [72%] of 25 vs five [31%] of 16 patients, respectively; P <.01). Sensitivity, specificity, and accuracy of a typical CT pattern for the diagnosis of ARDS(ex) were 72%, 69%, and 71%, respectively. Atypical appearances were characterized by more extensive nondependent intense parenchymal opacification (IPO) (P =.03) and cysts (P =.05), whereas typical CT appearances had more extensive dependent IPO (P =.01). Typical appearances at CT were independently related to the cause of ARDS (odds ratio, 8.9; 95% CI: 1.8, 44.2; P <.01) but were independent of the time from intubation. Foci of nondependent IPO were more extensive in ARDS(p) (P =.05) than ARDS(ex), but this finding was ascribable to differences in time to CT (after intubation) between ARDS(p) and ARDS(ex). CONCLUSION: The differentiation between ARDS(p) and ARDS(ex) can, with some caveats, be based on whether the CT appearances are typical or atypical of ARDS but not on any individual CT pattern in isolation.

Obstetric epidural analgesia in aortic stenosis: a low-dose technique for labour and instrumental delivery.

Five patients with valvular or fixed subvalvular aortic stenosis presented to a high-risk obstetric anaesthetic clinic over a 3-year period. All five were assessed during pregnancy and admitted at full term. A low-dose lumbar epidural analgesia regimen was used during labour and delivery. The use of pre-assessment and planned admission, invasive monitoring, epidural analgesia and interventional assisted delivery is discussed with reference to this patient group, and other aspects of peripartum management of concern to the anaesthetist.

Streptokinase resistance: when might streptokinase administration be ineffective?

OBJECTIVE: (a) To develop an assay for streptokinase resistance. (b) To determine the prevalence of streptokinase resistance in patients presenting with acute myocardial infarction for the first time. (c) To determine the prevalence of streptokinase resistance in patients after exposure to streptokinase or streptococcal infection. DESIGN: Open, prospective. PATIENTS: 30 healthy volunteers. 40 patients admitted to the coronary care unit at Addenbrooke's Hospital with suspected acute myocardial infarction, 12 patients 12 months after streptokinase treatment, eight patients 24 months after streptokinase treatment, and sera from 12 patients with raised anti-streptolysin O (ASO) titres. METHODS: Three assays were used; a dilution neutralisation assay, an enzyme linked immunosorbent assay (ELISA) for immunoglobulin G (IgG) anti-streptokinase antibodies, and an in vitro fibrin plate lysis assay. All measurements were performed on venous blood samples. RESULTS: Neutralisation and IgG antibody titres were positively correlated. Mean (SEM) antistreptokinase concentrations in the 30 controls were 87 (10) U/ml (neutralisation assay) and 28 (6.3) U/ml (ELISA). Corresponding concentrations in patients before streptokinase were 68 (6.1) U/ml and 18 (4.5) U/ml with a mean fibrin plate assay 117 (7.1)% that of controls. Resistance to streptokinase was detectable in one patient after 72 hours and in all patients by day 10. By day 10 concentrations were 4388 (919) U/ml, 773 (109) U/ml, and 17 (5.4)%. At both 12 and 24 months resistance was present in 75% of patients. Similarly 66% of high ASO titre sera showed resistance. The fibrin plate lysis assay detected significantly reduced streptokinase dependent fibrinolysis in vitro in the absence of raised total concentrations of antistreptokinase antibodies. CONCLUSIONS: The prevalence of streptokinase resistance in patients presenting with their first myocardial infarction is low. Resistance develops early after treatment and is still present in 75% of patients after 24 months. Retreatment with streptokinase is likely to be suboptimal even after 24 months. The fibrin plate lysis assay detects resistance in patients with normal concentrations of streptokinase antibodies. Streptococcal infection is associated with a high incidence of streptokinase resistance.