Performance and impact of an airway management team launched during the COVID-19 pandemic.

PURPOSE: To determine the performance and impact of an airway management team (AMT) assembled during the COVID-19 pandemic. METHODS: We conducted a retrospective cohort review of all adult patients who had received airway management services from the AMT (n = 269) and administered a survey questionnaire targeting physicians who had the option to activate the AMT (n = 77). The retrospective review determined the performance of the AMT, and the physicians' survey evaluated the impact of the AMT. The study was conducted at a large Canadian health centre (1,133 beds) from 28 March to 30 June 2020. We included patients in the cohort review who were ≥18 yr of age, whose chart showed that the AMT was activated, and whose airway was managed outside the operating room. We reviewed both electronic medical records and paper chart documentation. Outcomes included intubation success, number of intubation attempts, intubation time, team response time, patient contact time, intubation complications, and breaches of personal protective equipment (PPE) protocol. The physicians' survey evaluated the relevance, performance, reasonableness, and clinical utility of the AMT. RESULTS: The AMT intubated 231 patients. Charts showed that 91% of intubations were accomplished on first attempt. The mean (standard deviation) intubation time was 2.1 (0.2) min. The complication rate was minimal. The incidence of breaching PPE protocol items was less than 6%. No AMT members reported COVID-19 symptoms. The response rate for the physician's survey was 36%. The consensus among the participants was that the AMT had considerable clinical utility during the COVID-19 pandemic. CONCLUSION: An AMT assembled during the COVID-19 pandemic showed high competency and effectiveness, and had favourable impact on the main responsible physicians who activated the team.

RéSUMé: OBJECTIF: Déterminer la performance et l'impact d'une équipe de prise en charge des voies aériennes (AMT - Airway Management Team) assemblée pendant la pandémie de COVID-19. MéTHODE: Nous avons réalisé une revue de cohorte rétrospective de tous les patients adultes qui avaient bénéficié des services de prise en charge des voies aériennes par l'AMT (n = 269) et avons soumis un questionnaire aux médecins qui avaient eu la possibilité de faire appel à l'AMT (n = 77). La revue rétrospective a permis de déterminer la performance de l'AMT, et le sondage auprès des médecins a évalué l'impact de cette équipe dédiée. L'étude a été réalisée dans un grand centre de santé canadien (1133 lits) du 28 mars au 30 juin 2020. Dans la revue de cohorte, nous avons inclus des patients âgés de ≥18 ans, dans le dossier médical desquels il était fait mention de l'activation de l'AMT et dont les voies aériennes avaient été prises en charge à l'extérieur de la salle d'opération. Nous avons passé en revue à la fois la documentation des dossiers médicaux informatisés et des dossiers papier. Les résultats mesurés comprenaient le succès de l'intubation, le nombre de tentatives d'intubation, le temps pour intubation, le temps de réponse de l'équipe, le temps de contact avec le patient, les complications de l'intubation et les violations du protocole relatif aux équipements de protection individuelle (EPI). Le sondage auprès des médecins a évalué la pertinence, la performance, le caractère raisonnable et l'utilité clinique de l'AMT. RéSULTATS: L'AMT a intubé 231 patients. Les dossiers ont montré que 91 % des intubations ont réussi à la première tentative. Le temps moyen (écart type) d'intubation était de 2,1 (0,2) min. Le taux de complications était minime. L'incidence d'infractions aux articles du protocole pour les EPI était inférieure à 6 %. Aucun membre de l'AMT n'a rapporté de symptômes de COVID-19. Le taux de réponse au sondage auprès des médecins était de 36 %. Le consensus parmi les participants était que l'AMT était d'une utilité clinique considérable pendant la pandémie de COVID-19. CONCLUSION: Une équipe de prise en charge des voies aériennes assemblée pendant la pandémie de COVID-19 a démontré une compétence et une efficacité élevées et a eu un impact favorable sur les principaux médecins en charge qui ont fait appel à l'équipe.

Comprehensive Canadian review of the off-label use of recombinant activated factor VII in cardiac surgery.

BACKGROUND: This observational study sought to identify the off-label use pattern of recombinant activated factor VII (rFVIIa) in cardiac surgery and to identify predictors of its effectiveness and risk. METHODS AND RESULTS: At 18 Canadian centers, 522 nonhemophiliac cardiac surgical patients received rFVIIa during the period 2003 through 2006; data were available, and retrospectively collected, on 503 patients. The median (quartile 1, quartile 3) units of red blood cells transfused from surgery to therapy and in the 24 hours after therapy were 8 (5, 12) and 2 (1, 5), respectively (P<0.0001). Mortality rate was 32%, and mortality or major morbidity rate was 44%. These rates were within expected ranges (mortality, 27% to 35%; mortality or morbidity, 39% to 48%), which were calculated with a separate cohort of cardiac surgical patients who did not receive rFVIIa used as reference. Independent predictors of complications included instability before therapy (multiple inotropes or intra-aortic balloon pump) and increasing red blood cell units transfused before and after therapy. Variables independently associated with nonresponse included abnormal coagulation parameters and >15 red blood cell units transfused before therapy. CONCLUSIONS: In Canada, rFVIIa is used primarily when standard interventions have failed to control bleeding. In this setting, rFVIIa is associated with reduced blood product transfusions and, after risk adjustment, does not appear to be associated with increased or decreased complication rates. The effectiveness of the drug may be enhanced if it is given early in the course of refractory blood loss in the setting of adequate amounts of circulating coagulation factors.

The role of recombinant factor VIIa in on-pump cardiac surgery: proceedings of the Canadian Consensus Conference.

PURPOSE: Recombinant activated factor VII (rFVIIa) is currently not approved by Health Canada or the Food and Drug Administration for treating excessive blood loss in nonhemophiliac patients undergoing on-pump cardiac surgery, but is increasingly being used "off-label" for this indication. A Canadian Consensus Conference was convened to generate recommendations for rFVIIa use in on-pump cardiac surgery. METHODS: The panel undertook a literature review of the use of rFVIIa in both cardiac and non-cardiac surgery. Appropriateness, timing, and dosage considerations were addressed for three cardiac surgery indications: prophylactic, routine, and rescue uses. Recommendations were based on evidence from the literature and derived by consensus following recognized grading procedures. RESULTS: The panel recommended against prophylactic or routine use of rFVIIa, as there is no evidence at this time that the benefits of rFVIIa outweigh its potential risks compared with standard hemostatic therapies. On the other hand, the panel made a weak recommendation (grade 2C) for the use of rFVIIa (one to two doses of 35-70 microg.kg(-1)) as rescue therapy for blood loss that is refractory to standard hemostatic therapies, despite the lack of randomized controlled trial data for this indication. CONCLUSIONS: In cardiac surgery, the risks and benefits of rFVIIa are unclear, but current evidence suggests that its benefits may outweigh its risks for rescue therapy in selected patients. Methodologically rigorous studies are needed to clarify its riskbenefit profile in cardiac surgery patients.