Unintended consequences: The impact of airway management modifications introduced in response to COVID-19 on intubations in a tertiary centre emergency department.
Groombridge CJ, Maini A, Olaussen A, Kim Y, Fitzgerald M, Smit V. Unintended consequences: The impact of airway management modifications introduced in response to COVID-19 on intubations in a tertiary centre emergency department. Emerg Med Australas. 2021 Aug;33(4):728-733.
Objective: In response to COVID-19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first-attempt success (FAS) associated with ED intubation. Methods: An analysis of prospectively collected registry data of all ED intubations over a 3-year period at an Australian Major Trauma Centre. During the first 6 months of the COVID-19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with ‘sign-off’ for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre-drawn medications. Results: There were 783 patients, 136 in the COVID-19 era and 647 in the pre-COVID-19 comparator group. The rate of hypoxia was higher during the COVID-19 era compared to pre-COVID-19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID-19 vs 22.6% pre-COVID-19, P < 0.001). Other adverse events were similar before and during COVID-19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID-19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). Conclusions: This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.
Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID‐19 Pandemic
Caputo N, Strayer R, Levitan R. Academic Emergency Medicine 2020
OBJECTIVE Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19 pandemic. METHODS This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2. SpO2 measurements were recorded at triage and after five minutes of proning. Supplemental oxygenation methods included non-rebreather mask (NRB) and nasal cannula. We also characterized post-proning failure rates of intubation within the first 24 hours of arrival to the ED.RESULTS Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre- to post-median by the Wilcoxon Rank-sum test yielded P=0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. CONCLUSION Awake early self-proning in the emergency department demonstrated improved oxygen saturation in our COVID-19positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
Abstract
BACKGROUND:
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.
METHODS:
We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.
RESULTS:
The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy.
CONCLUSION:
The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.
Brewster D, Chrimes N, Do T et al. Medical Journal of Australia 2020. This a living document so please monitor the website for updates:
https://www.mja.com.au/journal/2020/212/10/consensus-statement-safe-airway-society-principles-airway-management-and
