key: cord-342642-qzoowc97 authors: garcía-méndez, nayely; lagarda cuevas, juan; otzen, tamara; manterola, carlos title: anesthesiologists and the high risk of exposure to covid-19 date: 2020-05-04 journal: anesth analg doi: 10.1213/ane.0000000000004919 sha: doc_id: 342642 cord_uid: qzoowc97 nan (1) ppe are all the set of elements and devices, that are specifically designed to protect the hcp against accidents and illnesses that could be caused by agents during the performance of their daily basis activities as well as in the emergency care; and (2) the occupational risk related to the exposure of the hcp must be identified and analyzed. 3 the joint commission international (jci) emphasizes that current status of ppe supplies remains inadequate to achieve minimum standards in most hospitals. the jci has been calling for action at all government levels to address the shortage and protect those who work heroically to care for infected patients with covid-19. we can confirm that in mexico, there have been "hospital outbreaks" with 329 hcps who have been infected with covid-19 throughout the country. planning an adequate distribution of ppe to health workers and developing appropriate strategies in clinics can diminish the impact of this pandemic on hcps. personal protective equipment for care of pandemic powered air purifying respirator prevención y control de infección en enfermedades respiratorias agudas con tendencia epidémica y pandémica durante la atención sanitaria pautas. available at: www.paho.org/es/documentos/ prevencion-control-infeccion-enfermedades-respiratoriasagudas-con-tendencia-epidemica para la vigilancia epidemiológica anesthesiologists and the high risk of exposure to covid-19 key: cord-318519-8sny5uq1 authors: hagan, katherine b.; raju, gottumukkala; carlson, richard; gottumukkala, vijaya title: to the editor date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004962 sha: doc_id: 318519 cord_uid: 8sny5uq1 nan to the editor w e thank drs rah and platovsky 1 for bringing attention to special considerations for gastrointestinal (gi) endoscopic procedures in an ambulatory care setting during the coronavirus disease of 2019 (covid-19) pandemic. as institutions endeavor to ensure safe endoscopic practices for emergent, urgent, and elective cases, distribution of personal protective equipment (ppe) and access to reliable sars-cov-2 (covid-19) testing remain key issues. we would join drs rah and platovsky 1 in arguing that endoscopy is especially high risk for several reasons: (1) upper and lower endoscopies are aerosolgenerating procedures (agps) 2 ; (2) these procedures involve bodily fluids that are known to carry the virus 3,4 ; (3) the procedure requires the gastroenterologist, technologist, and, at times, anesthesia provider to stand in close proximity to the site of aerosolization, 5 and, in the case of upper endoscopy, this places all 3 providers well within the 2-m zone for aerosolization; (4) many therapeutic procedures last ≥2 hours, with covid-19 well-documented in upper airway secretions and feces 3, 4 ; and (5) increased infectious risk to faculty and staff in the gi suite due to the higher case volumes and prolonged agps in these areas. endoscopy procedures with anesthesia pose additional risk for transmission of covid-19 infection to providers in the room due to intubation and extubation, which are aerosolizing procedures. even moderate sedation with total intravenous anesthesia (tiva) has added risks as patients without a secured airway tend to cough, aerosolize secretions, and/or require manual airway support (including intubation) in the midst of the procedure. therefore, we strongly recommend ppe use per center for disease control (cdc) guidelines for agps 6 and for all procedures in the gi endoscopy suite during the covid-19 pandemic. it is prudent that, at a minimum, all patients with risk factors (travel within 14 days, exposure to a positive patient, fever with or without respiratory symptoms) be tested the day before their procedure. furthermore, as highly sensitive diagnostic tests (rt-pcr) for covid-19 become widely available for routine use, we urge institutions to be cognizant of the risks associated with gi procedures and endeavor to institute testing of asymptomatic patients in these areas. we must remember that procedural areas such as endoscopy are not only associated with high patient volumes areas but also associated with prolonged agp interventions. determining urgent/emergent status of gastrointestinal (gi) endoscopic procedures in an ambulatory care setting during the coronavirus disease of 2019 (covid-19) pandemic: additional factors that need to be considered esge and esgena position statement on gastrointestinal endoscopy and the covid-19 pandemic temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov-2: an observational cohort study prolonged presence of sars-cov-2 viral rna in faecal samples staffing at ambulatory endoscopy centers in the united states: practice, trends, and rationale key: cord-343865-wbd0hqqc authors: singh, ajay; naik, b. naveen; soni, shiv lal; puri, g. d. title: real-time remote surveillance of doffing during covid-19 pandemic: enhancing safety of health care workers date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004940 sha: doc_id: 343865 cord_uid: wbd0hqqc nan to the editor t he global epidemiological crisis of coronavirus disease 2019 (covid-19) hints for strategic inspection, resource management, and responsiveness in infection control. worldwide a significant number of health care workers (hcws) have been infected till to date with asia-pacific region reporting 35 deaths and over 4000 quarantined cases, as on april 3, 2020. 1 hcws across the nation are anxious, unsure of personal protective equipment (ppe) availability, and whether it will provide enough protection or not. with alarming covid-19 case numbers, an overlooked facet of the ppe scarcity is whether hcws can use it properly without self-contamination. effective use of ppe by hcws is an integral part of covid-19 prevention in the health care setting. world health organization recommendations emphasize the importance of appropriate use of ppe, which requires correct and rigorous behavior from health care workers, particularly while doffing. 2 hospitals are scrambling to efficiently train a large number of noncritical care staff at short notice through simulation, webinars, and online courses on proper ppe donning and doffing practices. but experience from past infectious outbreak highlights the higher self-contamination rates as high as 46%-90% among hcws during doffing. 3, 4 even when hcws presume that they are trained enough, several factors may contribute to self-contamination during doffing-difficulty differentiating between dirty (outside) and clean (inside) surfaces, poorly fitting ppes, forceful movements, incorrect doffing sequence, and inconsistent ppe training. 5 therefore, an observer should watch the doffing process and alert hcw on any possible breach in safety. two-way audio-visual communication system with closed circuit television (cctv) cameras in the doffing area has the potential to ensure hcw safety from the offsite location through a trained observer, qualified to guide round the clock (figure) . observer follows the predefined checklist based on the centers for disease control and prevention (cdc) guideline for doffing, focusing on the visual screen. he will communicate, visually inspect, protect, and guide hcws through the protocols of doffing ppe. apart from adherence to the process of donning and doffing, the observer will ensure the disposal of used ppe from the doffing area. two-way audio-visual communication (with cctv cameras) in doffing area has the following advantages: • limits the risk of direct physical contact of the observer with potentially contaminated ppe of hcw. • limits ppe wastage. • allays hcw anxiety. • the low-cost surveillance system. asia-pacific health workers risk all to fight covid-19 rational use of personal protective equipment (ppe) for coronavirus disease (covid-19): interim guidance use of personal protective equipment among health care personnel: results of clinical observations and simulations alternative doffing strategies of personal protective equipment to prevent self-contamination in the health care setting healthcare workers' strategies for doffing personal protective equipment key: cord-347500-sigm6tos authors: vetter, thomas r.; pittet, jean-françois title: the response of the anesthesia & analgesia community to coronavirus disease 2019 date: 2020-04-27 journal: anesth analg doi: 10.1213/ane.0000000000004905 sha: doc_id: 347500 cord_uid: sigm6tos nan t he novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) first appeared in late 2019, most likely in wuhan, the capital city of the landlocked hubei province in the people's republic of china. in january 2020, sars-cov-2 was identified in an initial cohort of patients in wuhan who were acutely ill with viral pneumonia. in february 2020, sars-cov-2 was subsequently defined by the world health organization (who) as the causative agent of the emerging zoonotic coronavirus disease 2019 (covid-19). given not only the efficient human-to-human, droplet transmission of sars-cov-2 but also extensive domestic and international travel in and out of central china, covid-19 spreads rapidly. disease containment efforts largely failed, and the who in march 2020 declared a global pandemic status for this insidious virus and viral disease. at the time of writing this editorial in mid-april 2020, according to the very reputable covid-19 dashboard by the center for systems science and engineering at johns hopkins university (https:// coronavirus.jhu.edu/map.html), there have been worldwide 2,367,758 confirmed, documented cases of covid-19 and 163,134 reported disease-related deaths-equating to a 6.9% case fatality rate. there have hopefully been an equal or much greater number of mildly symptomatic or asymptomatic, undocumented cases of covid-19-thus promoting herd immunity as we intently await the development, large-scale production, and widespread availability of a safe and effective antiviral agent and/or vaccine. herd immunity (see appendix) occurs when enough of the population becomes immune to a disease like covid-19 for its sustained transmission to be disrupted. as more individuals become immune, newly infected ones are less able to transmit the disease, and the spread of the disease steadily decreases. this phenomenon provides an indirect form of protection for those who are not immune to the infectious disease. 1 covid-19 remains a rapidly evolving and thus very fluid disease-about which much is still unknown. however, what is clear is the tremendous adverse impact covid-19 is having on the health and wellbeing of the world's population. the current global pandemic is concomitantly putting enormous stress on health care systems and health care providers. in the absence of timely, valid, and pertinent information, many clinicians are inadequately informed and insufficiently prepared or equipped to manage this new disease. anesthesia & analgesia is committed to assisting our diverse audience in addressing the current covid-19 pandemic. we, thus, on march 18, 2020, issued a general call for related articles. we also solicited specific topical articles from various thought leaders and content experts. we greatly appreciate the outstanding efforts made by these authors-many of whom are working directly and tirelessly on their own health care frontlines-to promptly write these articles. we acknowledge the tremendous and vital contribution and team work of our journal editors, editorial support staff, and publisher. this covid-19 response has brought even greater awareness of the importance of the symbiotic relationship between anesthesia & analgesia and its affiliated specialty societies. to facilitate rapid publication, submitted articles focusing on covid-19 have undergone fast-track review, and if accepted, they were published online, with immediate free access, as soon as possible. we have assembled a number of these salient articles in the current themed issue of anesthesia & analgesia. other articles will be published in the coming months as more knowledge is gained about covid-19, including its longer-term effects on patients, their health care providers, and health ecosystems writ large. as presciently described in 3 articles in the july/ august 2005 issue of the journal foreign affairs, the recent emergence of a novel viral strain like sars-cov-2 and the ensuing covid-19 global pandemic were by all accounts biologically, historically, culturally, and politically inevitable. 2-4 covid-19 is only the most recent of a litany of so-called "emerging infectious diseases" that have opportunistically infected humans for centuries and likely for millennia. 5, 6 yet as rebecca solnit poignantly observed in her 2010 book titled, a paradise built in hell, "disaster doesn't sort us out by preferences; it drags us into emergencies that require we act, and act altruistically, bravely, and with initiative in order to survive or save the neighbors, no matter how we vote or what we do for a living." 7 each human generation has faced and effectively risen to meet its own unique, often defining, and seemingly existential challenge. and so we humbly and optimistically believe will likewise be our eventual and ultimate successful trajectory with covid-19. e appendix the contagiousness of a disease can be measured by its reproduction number (r 0 ), which is defined as the mean number of susceptible individuals who are expected to contract the disease (secondary cases) from exposure to a single infected person. for coronavirus disease 2019 (covid-19), r 0 is currently estimated to be 2-3. by comparison, seasonal influenza has an r 0 of 1.3; the 1918 influenza has an r 0 of 1.8; whereas rubeola has an r 0 of 12-18 (the highest of any infectious, communicable disease). the proportion of the population needed to become immune to achieve herd immunity (the herd immunity threshold) is calculated as 1 -(1/r 0 ). for severe acute respiratory syndrome coronavirus 2 (sars-cov-2), applying an r 0 value of 2.5, this equates to a herd immunity threshold of 60%. [8] [9] [10] herd immunity": a rough guide the next pandemic? foreign affairs preparing for the next pandemic the human-animal link emerging infectious diseases and pandemic potential: status quo and reducing risk of global spread the many faces of emerging and reemerging infectious disease built in hell: the extraordinary communities that arise in disaster the basic reproduction number (r0) of measles: a systematic review covid-19 r0: magic number or conundrum? complexity of the basic reproduction number (r0) key: cord-293473-32jx8j5g authors: maier, cheryl l.; barker, nicholas a.; sniecinski, roman m. title: falsely low fibrinogen levels in covid-19 patients on direct thrombin inhibitors date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004949 sha: doc_id: 293473 cord_uid: 32jx8j5g nan to the editor w e read with great interest ranucci et al's 1 review on the "trials and tribulations" of fibrinogen level determination that was recently published in anesthesia & analgesia. this topic has become even more important with the rise of the coronavirus pandemic since severe hyperfibrinogenemia is a characteristic finding in patients critically ill with coronavirus disease 2019 (covid-19) respiratory failure. 2 we wanted to take this opportunity to bring another limitation of the clauss method of fibrinogen determination to readers' attention, as it can have important implications for care of these patients. given the hypercoagulability seen in covid-19 patients, anticoagulation with low-molecular-weight heparin has been recommended by the international society of thrombosis and hemostasis. 3 however, since antithrombin levels can be significantly lower than normal in this patient population, 2 heparin's effectiveness may be limited in some cases. our institution has been selectively using direct thrombin inhibitors (dtis) to overcome this problem. unbeknownst to clinicians, this affected our laboratory's method for measuring fibrinogen levels, causing them to be vastly underestimated. an example of the magnitude in underestimation is provided in the figure for illustrative purposes. the clauss method of fibrinogen measurement is similar to a thrombin time. platelet poor plasma is exposed to a reagent containing supraphysiologic concentrations of thrombin and clot formation is sensed by mechanical or photo-optical means. the time to clot detection is compared against reference plasma to generate a corresponding fibrinogen level. the concentration of thrombin in the clauss reagent varies by manufacturer and what instrumentation is being used. when present in the patient sample, dtis inhibit the thrombin in the clauss reagent, prolonging the time to clot formation, and thus underestimating the fibrinogen concentration. reagents with lower thrombin concentrations are more susceptible to dti inference. this problem has been reported on several different commercial platforms with samples containing both bivalirudin and argatroban. 4, 5 the clauss assay in our particular laboratory uses a reagent with the highest commercially available thrombin concentration-100 nih units (unih)/ml (qfa thrombin, instrumentation laboratories, bedford, ma). despite this high level, "inhibitors" can still interfere with fibrinogen assessment. this can be assessed by performing a dilution procedure. this involves taking the patient plasma sample and performing a 1:1 dilution with hemosil factor diluent (instrumentation laboratories), a nonactive buffer solution. this reduces the effect of the dti. the figure provides an example of how large a difference this can make on the measurement of fibrinogen levels. viscoelastic testing represents an alternative to the clauss method for following fibrinogen levels in the setting of dtis. the platelet-fibrinogen interactions assessed by maximum amplitude on thromboelastography (teg) (haemonetics, boston, ma) or maximum clot formation on rotational thromboelastometry (rotem) (instrumentation laboratories) are relatively unaffected by the presence of dtis. 6 in the example provided in the figure, a rotem was obtained following the reported severe drop in fibrinogen on day 4 and resulted in the following notable parameters: extem clotting time of 477 seconds (normal range 43-82 seconds) and fibtem maximum clot firmness of 39 mm (normal range 7-24 mm). the clotting time was appropriately prolonged, indicating thrombin inhibition by the argatroban, while the increased maximum clot firmness was still able to reflect the hyperfibrinogenemia that was present. this discordance between the rotem findings and the reported fibrinogen level by the clauss method prompted the initial investigations into diluting the dti samples. the hypercoagulability caused by covid-19 is still not well understood. fibrinogen levels are an important piece of the puzzle, not only from a research aspect but for patient care. however, it is important for both scientists and clinicians to understand that their measurement is not always entirely straightforward. figure. the graph demonstrates an example of the magnitude of which an argatroban infusion can have upon the measurement of fibrinogen levels determined by the clauss assay. the patient's initially reported levels (blue line) on the day argatroban was started (which were repeated for confirmation) were almost an order of magnitude lower from previous measurements taken while on a heparin infusion. these samples were diluted as described in the text to decrease the effects of the argatroban and rerun, producing a "corrected" fibrinogen level (orange line). trials and tribulations of viscoelastic-based determination of fibrinogen concentration abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia isth interim guidance on recognition and management of coagulopathy in covid-19 low plasma fibrinogen levels with the clauss method during anticoagulation with bivalirudin influences of argatroban on five fibrinogen assays monitoring of argatroban and lepirudin anticoagulation in critically ill patients by conventional laboratory parameters and rotational thromboelastometry -a prospectively controlled randomized double-blind clinical trial key: cord-296725-ecy0rie9 authors: landau, ruth; bernstein, kyra; mhyre, jill title: lessons learned from first covid-19 cases in the united states date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004840 sha: doc_id: 296725 cord_uid: ecy0rie9 nan to the editor t here is a real paucity of data surrounding best anesthesia management of pregnant women tested positive for severe acute respiratory syndrome coronavirus 2 (sars-cov-2; coronavirus disease-2019 ). the simultaneous surge of cases compounded by a critical shortage of protective personnel equipment (ppe), including n95 masks and high-efficiency particulate air (hepa) filters to avoid contaminating anesthesia machines, has added to the challenge that anesthesiologists are facing today on labor and delivery units across the united states. reflecting on the review of covid-19-positive patients reported in this issue of anesthesia & analgesia, 1 we noted that 43% of women were delivered before term, that 71% presented with fever, and that evidence of pneumonia by computed tomography was reported in all patients. almost all women (13 of 14) had a cesarean delivery, all with an uncomplicated neuraxial anesthesia and no neurological complications. that neuraxial anesthesia is safe in women with covid-19 is reassuring, given that it is always preferred to general anesthesia, and specifically to avoid viral aerosolization and wastage of dwindling medical equipment and ppe. the reality is that all recommendations have centered on the risk stratification of patients; persons under investigation (pui) or patients who have been tested and known to be covid-19 positive should be cared for with appropriate ppe. current recommendations include airborne protection for all aerosolizing procedures such as endotracheal intubation during general anesthesia. 2,3 however, universal testing has not been available in most institutions in the united states, and women may be asymptomatic when admitted in the labor and delivery unit in spontaneous labor. further, the signs and symptoms of labor, including shortness of breath, fever in labor, diarrhea, myalgias, and chest tightness, may overlap with symptoms of covid-19 and obscure the diagnosis. an asymptomatic parturient who presents as covid-19 positive later in the labor course has not been described in the case series reported so far, which has prompted us to share our experience. a healthy, asymptomatic multiparous woman was admitted for induction of labor at 37 weeks of gestation for gestation diabetes, and neuraxial analgesia was provided uneventfully. hours later, an intrapartum cesarean delivery under epidural anesthesia was completed for prolonged second stage of labor and a diagnosis of chorioamnionitis with maternal fever. after delivery of the baby, a postpartum hemorrhage and atony treated with massive transfusion and uterotonics required conversion to general anesthesia; endotracheal intubation precipitated immediate and prolonged bronchospasm. though bronchospasm could be attributed to carboprost tromethamine (hemabate; pharmacia & upjohn co, division of pfizer inc, new york, ny), the degree of respiratory decompensation and the fever in labor prompted a nasal swab for covid-19 testing, which came back positive 4 hours later. as per current recommendations, for this patient who was neither tested nor symptomatic for covid-19, the anesthesia team did not use any ppe (besides surgical masks and gloves) nor was a hepa filter placed between the endotracheal tube and the anesthesia machine. in this scenario, had it been suspected that the patient was covid-19 positive, all providers would have been wearing airborne protection (gown, gloves, n95 with face shield or powered air-purifying respirators [paprs]) and a filter would have been placed. our case emphasizes that in labor and delivery units managing parturients from communities with a high prevalence of covid-19 infection, in the absence of universal testing before cesarean delivery, all patients, even those initially asymptomatic on admission, should be treated as pui when inducing general anesthesia. we hope this case will raise awareness to use appropriate measures to avoid personnel exposure and equipment contamination, and that in the absence of universal testing, universal precautions are required. neuraxial procedures in covid-19 positive parturients: a review of current reports novel coronavirus (covid-19) anesthesia resource center society for obstetric anesthesia and perinatology (soap) interim considerations for obstetric anesthesia care related to covid-19 key: cord-254266-6ca2d79d authors: loftus, randy w.; dexter, franklin; parra, michelle c.; brown, jeremiah r. title: in response: "perioperative covid-19 defense: an evidence-based approach for optimization of infection control and operating room management" date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004854 sha: doc_id: 254266 cord_uid: 6ca2d79d nan d r maguire 1 considers the use of patient decolonization to aide in the prevention of perioperative viral transmission. 2 the evidence, outlined below, favors our recommended approach, given the coronavirus disease 2019 (covid-19) pandemic. 2 first, the patient reservoir is a critical factor contributing to disease transmission that must be addressed. [3] [4] [5] we evaluated the impact of an evidence-based, multifaceted approach on perioperative staphylococcus aureus transmission and surgical-site infections (ssis) in a randomized clinical trial. 6 attention to improved hand hygiene, patient decolonization, vascular care, and environmental cleaning generated substantial reductions in s. aureus transmission and ssis, especially when optimized by surveillance of transmission. 6 second, povidone-iodine and chlorhexidine have broad-spectrum activity. povidone-iodine is a complex of povidone, hydrogen iodide, and elemental iodine that targets structures needed for survival and replication (eg, neuraminidase for viral propagation via infection of noninfected cells and hemagglutinin for attachment). this results in multimodal activity. 7 povidone-iodine has rapid and effective virucidal activity against the middle east respiratory syndrome coronavirus (mers-cov) and modified vaccinia virus ankara (mva) with at least a 4 log 10 (99.99%) inactivation of both pathogens within 15 seconds. 7, 8 this represents more antiviral potency than alcoholic and nonalcoholic hand sanitizers and soaps. 7 our reason for using chlorhexidine gluconate was that it is available in the us as peridex oral rinse. while chlorhexidine gluconate is less effective than povidone-iodine, 8 it has activity against enveloped viruses on skin and in the oral cavity (0.12%) with viral inactivation in as little as 30 seconds. 9 the inactivity of chlorhexidine rinse against the poliovirus is presumed to be related to lack of an envelope. 9 because the covid-19 virus is enveloped, chlorhexidine gluconate 0.12% is likely to have similar activity against the virus as it does against other enveloped viruses. 10 third, povidone-iodine and chlorhexidine gargle reduce the spread of viruses. the mers outbreak showed that human-to-human transmission often involved close contact and the health care arena. 7, 8 therefore, improvements in hygiene practices, such as patient decolonization, can help combat the spread of covid-19. povidone-iodine preparations reduce viral loads of the patient skin, oropharynx, and nasopharynx. 7, 8 the agent is included in the world health organization's list of essential medicine for addressing the spread of other viral pathogens of global concern (ie, hepatitis a, influenza, and the mers). 7, 8 povidone-iodine is provided in both skin preparation and oral gargle formulations, has antiinflammatory activity, has an excellent safety profile, and no resistance identified to date. 7, 8 finally, povidone-iodine and alcohol-based hand rubs are more effective than soap-based hand washes for hand hygiene in the presence of transmissible viruses 11, 12 and povidone-iodine has been shown to prevent the spread of contagious conjunctivitis. 13 fourth, nasal povidone-iodine is formulated to prevent nasal irritation. 14 nasal povidone-iodine is thickened, and ph balanced, to be nonirritating, to have a sustained effect, and to address the physiology of the nose. 14 we observed no issues with sneezing or coughing induced by nasal povidone-iodine 14 in our randomized trial. 6 the product 14 was well tolerated and without adverse events. the authors are unaware of reports suggesting otherwise. fifth, the authors are unaware of evidence suggesting that chlorhexidine gluconate 0.12% oral rinse is associated with inducing cough. this hypothetical concern raised by dr maguire 1 should be balanced against the substantial evidence that the oral reservoir contains a high viral load that should be attenuated to prevent the spread of covid-19 and that 0.12% chlorhexidine gluconate may be useful in achieving this goal. [7] [8] [9] whether the alternative of povidoneiodine oral rinse is more effective is currently unkn own. 7, 8, 11, 12, 15 in conclusion, the evidence shows a favorable risk/benefit profile for our recommendation of patient decolonization with nasal povidone and oral chlorhexidine rinse to help mitigate the perioperative spread of covid-19. [7] [8] [9] [10] [11] [12] if substantial concerns remain (eg, sneezing and/or coughing), we would recommend using the agents after patient induction and stabilization. given the severity of the covid-19 pandemic, we believe that it would be ill-advised to avoid use of these evidence-based preventive measures. these steps are part of a comprehensive program that stands on a solid body of published evidence established during the past 14 years. [2] [3] [4] [5] [6] in response: "perioperative covid-19 defense: funding: the original study was funded in part by the anesthesia patient safety foundation and by the department of anesthesia, university of iowa. completion of the letter was funded by the department of anesthesia. conflicts of interest: r. w. loftus reported research funding from sage medical inc, bbraun, draeger, and kenall, has one or more patents pending, and is a partner of rdb bioinformatics, llc, and 1055 n 115th st #301, omaha, ne 68154, a company that owns or pathtrac, and has spoken at educational meetings sponsored by kenall (aorn) and bbraun (apic). m. c. parra is affiliated with rdb bioinformatics, llc, as r. w. loftus' spouse. the remaining authors declare no conflicts of interest. oral and nasal decontamination for covid-19 patients: more harm than good? anesth analg perioperative covid-19 defense: an evidence-based approach for optimization of infection control and operating room management the epidemiology of staphylococcus aureus transmission in the anesthesia work area high-risk staphylococcus aureus transmission in the operating room: a call for widespread improvements in perioperative hand hygiene and patient decolonization practices the anesthetists' role in perioperative infection control: what is the action plan? improving basic preventive measures in the perioperative arena to reduce s. aureus transmission and surgical site infections, a randomized trial rapid and effective virucidal activity of povidone-iodine products against middle east respiratory syndrome coronavirus (mers-cov) and modified vaccinia virus ankara (mva) infectious disease management and control with povidone iodine in vitro virucidal effectiveness of a 0.12%-chlorhexidine gluconate mouthrinse coronaviruses: an overview of their replication and pathogenesis bactericidal and virucidal activity of povidoneiodine and chlorhexidine gluconate cleansers in an in vivo hand hygiene clinical simulation study surgical hand preparation with chlorhexidine soap or povidone iodine: new methods to increase immediate and residual effectiveness, and provide a safe alternative to alcohol solutions epidemic keratoconjunctivitis: prevention strategies in the clinic povidone-iodine solution 5% w/w [0.5% available iodine] usp) patient preoperative skin preparation stability of sars-cov-2 in different environmental conditions key: cord-336973-z8mwzmf6 authors: rubulotta, francesca; soliman-aboumarie, hatem; filbey, kevin; geldner, goetz; kuck, kai; ganau, mario; hemmerling, thomas m. title: in response date: 2020-07-14 journal: anesth analg doi: 10.1213/ane.0000000000005121 sha: doc_id: 336973 cord_uid: z8mwzmf6 nan in response w e thank esteemed colleagues drs brull and kopman, 1 both well-known experts in the field of neuromuscular monitoring and blockade for their interest in our article and their comments. we would like to start by reiterating that our review 2 was aimed at presenting technologies and techniques for coronavirus disease 2019 (covid-19) patients who needed the use of neuromuscular blocking agents (nmba) outside the operating theater. in particular, the editorial focused on severe covid-19 patients with acute respiratory distress syndrome (ards). nmba were needed for either intubation in the intensive care unit (icu) or emergency room (er) or for sparing these drugs during prolonged invasive mechanical ventilation. 2 the creation of dedicated anesthesia intubation teams during the covid-19 crisis as well as the increasing engagement of anesthesiologists in the icu setting led us to believe that presenting basic principles of neuromuscular monitoring could be of interest for all readers. 2 we purposely adopted the terminology widely used in the setting of intensive care medicine 3 when we wrote about the train-of-four (tof) monitoring. as a matter of fact, we deliberately referred to the way electric impulses are applied to a motor nerve. the tof stimulation consists of applying 4 electric stimuli each separated by 0.5 s. depending on the method of monitoring available, either qualitative-tactile or visual counting-or quantitative monitoring-using a specific monitoring device-is possible. in the former, the tof count can be determined (1-4 twitches), or a definite ratio of t4/t1 ratio. the tof ratio is the comparison of t4 (fourth twitch of the tof) to t1 amplitude, expressed in percentage. 4 we left the choice of using either qualitative or quantitative monitoring to the discretion of the physicians working in the icu because they could be not icu trained. 2 in the operating room, quantitative monitoring devices are recommended as they give a more detailed and precise estimate of neuromuscular blockade (nmb). nmb monitoring is not standard of care in the icu, despite the infusion of nmbas is common for adult with severe ards or during proning maneuvers. the best compromise between practicability, usefulness, and validity of monitoring seems to be the use of qualitative, handheld monitoring devices. 2 handheld monitoring has limited value during intubation outside the icu but it can be easily carried in the physician's pocket, and properly disinfected. 2 monitoring is more frequently used during continuous infusion of nmba and it can be done in seconds using facial or eye muscles, adductor pollicis muscle, or others. the qualitative result can then be noted in the electronic patients' chart. the frequency and the site of placement of such monitoring is also discretion of the treating physician or the icu guidelines. the covid-19 pandemic peak has significantly increased the workload in most icus and the frequency of tof monitoring has been compromised at times. even if 1 attempted quantitative monitoring in the icu, validity of the results could be questioned because of the lack of standardization. frequently asked questions are: shall one leave stimulating electrodes in the same place? how long could these stay on the skin without causing pressure damages? what position shall be used of the hand when monitoring is performed? in that respect, again facial muscles are easier to monitor but they do not reflect nmb or neuromuscular transmission at the adductor pollicis muscle. we do not recommend the corrugator supercilii as the monitoring site of choice but wanted to point out that it best reflects nmb or neuromuscular transmission at the diaphragm or larynx, anatomic areas of particular interest for icu physicians. drs brull and kopman 1 questioned the recommended target value of nmb in the icu setting. the discussion of whether nmb is at all necessary for mechanical ventilation in the icu is beyond the scope of our article. however, in a recent study, 3 a positive relationship was found between the depth and duration of nmb and icu-acquired weakness. the article entitled "battle of the rsi paralytics" 5 describes the long-standing discussion around the use of succinylcholine versus rocuronium for rapid sequence induction (rsi) from the perspective of emergency medical services. in terms of onset time and intubation conditions, rocuronium in a dose of more than 1 mg/kg and succinylcholine in a dose of 1 mg/kg are equally efficient. 6 covid-19 patients who need intubation are predominantly suffering from multiple comorbidities. 7 this leaves us with the eternal question which muscle relaxant is better for the "can't intubate can't ventilate situation." despite best efforts of preoxygenation, covid-19 patients desaturate very quickly during the intubation process to alarming values of 70% or 60% or less within seconds. it is therefore important that intubation is provided by a dedicated team and mostly by the very experienced physicians, predominantly using videolaryngoscopy. 2 the procedure can be particularly challenging in covid-19 patients. naguib et al 8 found a significantly longer objectively measured duration of nmb after 1 mg/kg succinylcholine with 10 minutes versus 2 minutes after 1.2 mg/kg rocuronium followed 3 minutes later by 16 mg/kg sugammadex. as to the comments by brull and kopman 1 to the time it takes to get this amount of www.anesthesia-analgesia.org letters to the editor sugammadex is ready, one can easily imagine the fractionated injection of sugammadex by the anesthesiologist, while a second person gets it ready. we argue that the time it takes to get sugammadex ready is not really an issue. however, no one can prove that the risks and benefits ratio of using rocuronium is better for those administering succinylcholine in these situations. even when one looks at clinical parameters, such as a return to spontaneous ventilation, defined as respiratory rate of more than 8/min at a tidal volume of at least 3 ml/kg for 30 s, the combination of rocuronium/sugammadex is able to achieve this in half the time as succinylcholine. 9, 10 clarifications on technologies to optimize care of severe covid-19 patients technologies to optimize the care of severe covid-19 patients for healthcare providers challenged by limited resources clinical assessment and train-of-four measurements in critically ill patients treated with recommended doses of cisatracurium or atracurium for neuromuscular blockade: a prospective descriptive study monitoring of neuromuscular block towards evidence-based emergency medicine: best bets from the manchester royal infirmary. bet 3: is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation? staff safety during emergency airway management for covid-19 in hong kong the myth of rescue reversal in "can't intubate, can't ventilate" scenarios rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial effects of neuromuscular block on systemic and cerebral hemodynamics and bispectral index during moderate or deep sedation in critically ill patients the authors thank umesh patel for editing the content. key: cord-345136-zcd00lcw authors: kapp, christopher m.; zaeh, sandra; niedermeyer, shannon; punjabi, naresh m.; siddharthan, trishul; damarla, mahendra title: the use of analgesia and sedation in mechanically ventilated patients with covid-19 ards date: 2020-07-14 journal: anesth analg doi: 10.1213/ane.0000000000005131 sha: doc_id: 345136 cord_uid: zcd00lcw nan to the editor w e read with great interest in the article by hanidziar and bittner. 1 we have observed high sedation requirements in our coronavirus disease 2019 (covid-19) patient population and sought to quantify the administered doses to characterize sedation needs in these patients with critical illness. we compared the quantity of sedation used in this population to the quantity of sedation described in a prior study of patients with ards. 2 we included the first 24 adult patients with confirmed severe acute respiratory syndrome coronavirus 2 (sars-cov-2) admitted to the johns hopkins hospital (jhh) medical intensive care unit (micu) between march 15 and march 28, 2020. nineteen patients required mechanical ventilation. all sedation management decisions were made by icu physicians, and dosing titrated by staff using the richmond agitation and sedation scale (rass). 3 practice guidelines for mechanically ventilated patients at the jhh micu include the use of analgesia first with intermittent boluses of sedatives followed by continuous drips as warranted. doses of analgesic and sedative medications were collected from the medical record, summed into daily totals for each patient, and converted into oral morphine and midazolam equivalents via established conversions. 4, 5 day 1 was the date of intubation or day of admission to jhh micu if previously intubated and typically did not represent a full 24-hour period. this retrospective review was approved by the local institutional review board (irb00248523). all statistical analyses were conducted using graphpad prism 7.05. the study sample included 24 patients, 19 of which were intubated, and included 15 men (63%), with a median age of 56 years (range: 31-80 years). before icu admission, 1 patient had preexisting liver disease and another had end-stage renal disease. before being hospitalized, 2 patients had opiate use and 1 patient had benzodiazepine use. the figure depicts daily dosages of opiates and benzodiazepines administered to mechanically ventilated patients. day 1 dosages were significantly lower, likely related to the variability in hours during the first day of mechanical ventilation. all 19 patients required continuous intravenous opioid and midazolam infusions. from day 2 to 7, when most patients remained intubated, the median daily dose of oral morphine equivalents was 775 mg (interquartile range [iqr], 648.4-899.7 mg) and for oral midazolam equivalents was 270.9 mg (iqr, 201.3-304.4 mg). of the patients who underwent neuromuscular blockade, the median daily dose of opiates (in oral morphine equivalents) and benzodiazepines (in oral midazolam equivalents) was 937.2 mg (iqr, 667.7-1683 mg) and 224.7 mg (iqr, 56.56-610 mg), respectively. for patients who did not receive neuromuscular blockade, the median daily dosage of opiates (in oral morphine equivalents) and benzodiazepines (in oral midazolam equivalents) was 623.8 mg (iqr, 176.3-726.9 mg) and 135 mg (iqr, 40.63-203.8 mg), respectively. propofol (16 of 19 patients, 84%), dexmedetomidine (10 of 19, 53%), and ketamine (2 of 19, 11%) were also used at the discretion of the icu providers. the highest use of propofol was administered at time of intubation and occurred on day 1 of mechanical ventilation. dexmedetomidine was used as an adjunctive sedative. fourteen patients (74%) received antipsychotics, typically to facilitate extubation. of the 19 patients requiring mechanical ventilation, 13 (68%) underwent prone positioning and 10 (53%) received neuromuscular blockade. five patients died during their icu stay (21%). duration of endotracheal intubation was a median of 11 days, with a range of 3-37 days. three patients received a tracheostomy. high analgesic and sedative medication requirements were observed in a cohort of patients with covid-19related ards, with doses exceeding those previously documented in the literature for patients with ards. 2 notably, the opioid doses in our cohort were more than 3 times higher, and our midazolam doses were also higher than historical cohorts. participants in the oscillate trial had median fentanyl doses of 2980 µg (iqr, 1258-4800 µg) which converted to a median of 289 mg (iqr, 125.8-480 mg) oral morphine equivalents. participants in oscillate had median midazolam doses of 199 mg (iqr, 100-382). 2 while not perfectly matched, the cohorts had a similar length of intubation and similar p:f ratios at the time of intubation. the average apache-2 score was lower in our cohort-19.6 vs 29. 2 there are a number of factors that likely contributed to higher doses of analgesic and sedative medications in this setting. first, the majority of patients required neuromuscular blockade which is accompanied by www.anesthesia-analgesia.org letters to the editor deep sedation targets, frequently requiring high doses of analgesia and sedation. second, most patients in this cohort and broadly speaking with covid-19 have high fevers, increasing ventilatory drive and possibly leading to more ventilator dyssynchrony, necessitating additional sedation. interestingly, patients received disproportionately higher amounts of opiates than benzodiazepines, likely to reduce respiratory drive. third, challenges to entering patient rooms frequently in the setting of personal protective equipment requirements may have resulted in reduced downward titrations of continuous infusions. fourth, concerns over patient harm (ie, self-extubation) may have led to higher medication doses. finally, our cohort had a median age of 56 years and minimal liver or kidney dysfunction, potentially promoting faster metabolism of medications compared to cohorts of older patients with multiorgan dysfunction, though the oscillate cohort had a mean age of 54-55. 2 while large dosages of analgesic and sedative medications are typically associated with longer duration of mechanical ventilation, the experience in this cohort showed a median duration of 11 days of mechanical ventilation, which is similar to other trials of ards. although this report represents a limited sample size at a single center, it provides initial insight into analgesia and sedative use among mechanically ventilated patients with covid-19. the current pandemic has proven to be a unique challenge to continue established sedation protocols and practices aimed to reduce analgesia and sedative medications. 6 the impact of large doses of sedation in patients with covid-19 remains to be seen. a previous study has described an increased incidence of delirium with high levels of sedation, as well as long-term cognitive impairment. 7 while further study focused on the physical and cognitive impact is needed, focus on methods to safely minimize analgesia and sedative dosages is also warranted. sedation of mechanically ventilated covid-19 patients: challenges and special considerations highfrequency oscillation in early acute respiratory distress syndrome monitoring sedation status over time in icu patients: reliability and validity of the richmond agitation-sedation scale (rass) benzodiazepine equivalents conversion calculator equianalgesic dose ratios for opioids. a critical review and proposals for long-term dosing daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial delirium as a predictor of long-term cognitive impairment in survivors of critical illness the median and interquartile range of daily opiate (mg oral morphine equivalents) and benzodiazepine use (mg oral midazolam equivalents) is shown per day of mechanical ventilation at jhh. the number of patients receiving opiates key: cord-336423-rs4bma9b authors: endersby, ryan vincent william; ho, esther ching yee; spencer, adam oscar; goldstein, david howard; schubert, edward title: barrier devices for reducing aerosol and droplet transmission in coronavirus disease 2019 patients: advantages, disadvantages, and alternative solutions date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004953 sha: doc_id: 336423 cord_uid: rs4bma9b nan to the editor w e read with interest the articles by brown et al, 1 lai and chang, 2 tsai, 3 and babazade et al. 4 these articles describe barrier devices for potentially reducing aerosol and droplet transmission in coronavirus disease 2019 (covid-19) patients. brown et al 1 and babazade et al 4 describe the use of plastic drapes, whereas lai and chang 2 and tsai 3 describe rigid box designs. [1] [2] [3] [4] although these designs are innovative, they do suffer from some important drawbacks. rigid box designs significantly limit forearm and hand movements and might require some practice to achieve competence in use. 2, 3 in addition, the rigid design forces assistants to stand far off to the side of the patient, which limits help with airway management and does not offer them the same protection provided to the laryngoscopist. these designs can require initial elaborate construction, such as tsai's 3 design. lai and chang's 2 design, although less elaborate in construction, lacks transparency of other models, possibly making its use even more challenging. 2 reusable designs of tsai 3 might also have the added issue of having to be decontaminated, which might be a problem in nonmedical grade devices. 3 plastic drape cover designs of brown et al 1 and babazade et al 4 have the advantage of being inexpensive, commonly available, quick to produce, and disposable. 1, 4 they also have multiple access points for assistance; however, the weight of the plastic drape on proceduralist's hands still might be an issue when performing procedures under the device. the plastic drape is also quite close to the patient's face and this might not be tolerated by some patients. to overcome some of these limitations, we constructed a hood to encase the patient's head during procedures (figure) . it consists of a surgical mayo stand without the tray and a clear plastic drape allowing clear visualization of the patient's head and neck. the plastic drape is a c-arm drape cut along a side seam and the bottom, forming a large sheet of clear plastic. this can be draped over the mayo stand. we tested our device with glo-germs administered using a madgic laryngo-tracheal mucosal atomization device to simulate the production of fine droplets and aerosol. when utilizing the hood, visible glo-germ spread was confined to the clinician's hands, forearms, intubating manikin's head, neck, and the operating table covered by the hood. without the hood, glo-germ could be identified on the laryngoscopist's hands, entire arms, gown, neck, face, eye protection, mask, and more extended spread around the operating room. as standard masks were used, we also noticed an interesting qualitative difference when the hood was used. fine droplet glo-germ produce a distinctive smell when aerosolized, and this was noticed by the laryngoscopist only when the hood was not used. we believe our hood maintains the advantages of the barrier design with it offering adequate space around a patient's head and neck for both the laryngoscopist and assistant to provide effective airway management from preoxygenation to extubation. additional simulation studies as well as studies involving aerosol behavior in relation to the barrier devices are warranted. such data will allow more confident approaches to techniques meant at providing protection during airway management. barrier system for airway management of covid-19 patients a carton-made protective shield for suspicious/confirmed covid-19 intubation and extubation during surgery barrier shields additional barrier to protect healthcare workers during intubation key: cord-327388-26ot3cuy authors: lu, amy; cannesson, maxime; kamdar, nirav title: the tipping point of medical technology: implications for the postpandemic era date: 2020-06-16 journal: anesth analg doi: 10.1213/ane.0000000000005040 sha: doc_id: 327388 cord_uid: 26ot3cuy nan t he unprecedented challenges of coronavirus disease 2019 (covid-19) have pushed the limits of medicine and health care over the tipping point of what we thought imaginable, forcing solutions to problems that previously mired rapid progress. nowhere has this been more apparent than in technology, where both its accelerated advances and shortcomings have come into sharp contrast during the current pandemic. whereas classic infectioncontrol and public health measures were used during the severe acute respiratory syndrome (sars) epidemic in 2003, covid-19 provides the opportunity to explore the potential of new digital technologies, including big data analytics, artificial intelligence, blockchain technology, and the internet of things. 1 among the many available digital technologies, o'reilly-shah et al 2 in this issue of anesthesia & analgesia address not only the potential benefits but also the barriers to adopting health informatics for patient care during the covid-19 pandemic. 2 they review concerns around current gaps in technology, including data privacy and ethics, we well as data silos and sharing. they highlight the lack of data infrastructure and interoperability as barriers to patient care and public health efforts during the pandemic. a recent study similarly observed that barriers to public health agencies receiving hospital-level data on covid-19 patients included the inability to electronically receive data, interface-related issues, difficulty extracting data from the electronic health record (ehr), and different vocabulary standards. 3 o'reilly shah et al 2 also highlight concrete examples of the pandemic pushing the creative edges of technology. 2 like other authors, 4 they note the proliferation of clinical decision support tools such as best practice alerts, order sets, and dashboards designed to track real-time covid-19 updates in a hospital. while o'reilly-shah et al 2 review the advantages and gaps currently existing specifically in clinical informatics, 2 technology-in all of its forms-is rapidly evolving to address the pandemic. the apparent transition to the postinitial surge phase of the covid-19 pandemic serves as an inflection point to reflect on the potential technological contributions of anesthesiology and anesthesiologists. considering the expansive array of digital technologies available to contemporary health care, we take the liberty in this current editorial to discuss the anesthesiologist's optimal role in this broader arena. indeed, equally relevant to any discussion on technological innovation are the creative nondigital solutions that have been implemented during the initial covid-19 surge. many of these were developed by necessity, such as alternative personal protective equipment (ppe) options and reprocessing and sterilization techniques for n95 respirator masks. critical the tipping point of medical technology: implications for the postpandemic era shortages of ppe-motivated amateurs and expert manufacturers to utilize 3-dimensional (3d) printing to create medical supplies like face shields, face masks, and nasal swabs. novel medical technologies like intubation boxes to minimize aerosolization, splitting ventilators, and new severe acute respiratory syndrome coronavirus 2 (sars-cov-2) testing and treatment options are continually being developed. the specialty of anesthesiology has a strong track record of innovations in medical device technologywitnessed again with covid-19. we posit, however, that the current pandemic offers a unique opportunity to contribute to emerging digital technologies that have not been conventionally considered part of the purview of anesthesiology. this includes expanding our roles in telehealth platforms and remote monitoring and surveillance in the inpatient and outpatient settings, thereby adding significant value to the continuum of care through perioperative medicine. as we expand these technologies, it will be incumbent upon us to apply equally innovative metrics to measure the clinical and quality outcomes of these interventions in the perioperative setting. one of the most striking transformations during the current pandemic has been the rapid adoption of telehealth and telemedicine. before the emergence of covid-19, despite impressive advances in video and mobile technology, telehealth progress was stymied by highly restrictive stipulations by the us centers for medicare & medicaid services (cms), state boundaries, and poor reimbursement. the pandemic has spurred federal and state regulators to level the playing field by reducing barriers to telehealth adoption, including reimbursement parity laws and relaxing state geographical restrictions. the expansions also included several cms emergency initiatives that expanded medicare and medicaid coverage, increasing the modalities and sites of coverage, such as personal residences, federally qualified health centers, and rural clinics. 5 congress passed relief bills allowing the us department of health and human services to approve telehealth grants, and the federal communications commission started a covid-19 telehealth program. states followed suit with emergency directives to increase telehealth access and coverage. state-level, covid-19-related shelter-in-place mandates prompted rapid implementation efforts highly relevant for the vast majority of specialties, including anesthesiology. [6] [7] [8] as early adopters of telemedicine in the perioperative setting, our respective health systems realized a marked increase in opportunities to expand virtual preoperative consultation for patients. facilitating the expansion of telehealth platforms simultaneously assisted staff and patients to adhere to statewide shelter-in-place mandates, reduce risk of exposure, and preserve ppe during the initial surges of the pandemic. 9 the preoperative anesthesia clinics at our health systems rapidly adapted our existing telehealth workflow, allowing us to continue to risk stratify, optimize, and prioritize surgical cases when elective procedures were postponed. anecdotally, one of our institutions implemented an increase from 30% audiovideo visits to nearly 100% within one business day. our experiential learning from this radical transformation reflects what others have reported about their telehealth experiences during the pandemic. 6 the challenges, opportunities, and solutions experienced by our preoperative medicine and pain medicine clinics during this transition are listed in table 1 . the initial covid-19 pandemic surge and shelterin-place mandates reduced our capability to perform a conventional physical examination of our patients, leading to the creative application of remote patient monitoring (rpm) and surveillance technologies. in the ambulatory setting, we shifted our reliance on patient-entered outcome data to remote monitoring in several scenarios, including continuous glucose monitors for glycemic control of insulinoma patients; bluetooth weight scales for patients with congestive heart failure; consumer actigraphs to evaluate activity levels; and bluetooth-enabled blood pressure cuffs to titrate alpha-blockade of pheochromocytoma patients. within the hospital, remote surveillance offers unique abilities to safety monitor patients in nonintensive care unit (icu) settings while conserving scarce medical equipment and ppe. safavi et al 10 describe the prerequisites and limitations for proper remote surveillance so clinicians can identify patients at risk for physiological deterioration. 10 their technological blueprints illustrate the importance of electronic medical records (emr)-based database structures and data lakes and the design challenges to assure reliable information access and interpretation. knowledge gained from the inpatient setting has direct application for monitoring infectious disease outside the hospital using patient self-entered clinical data. for example, institutions across the country have implemented ehr-embedded tools to remotely monitor asymptomatic, covid-positive patients at home 11 ; and to detect physiological deterioration with remote monitoring (pulse oximetry and temperature), asynchronous questionnaires, and video visits to advise a return to the hospital or clinic only if a patient becomes febrile or dyspneic or exhibits oxygen desaturation. 12 xxx xxx • volume xxx • number xxx www.anesthesia-analgesia.org 3 this progress made in covid-19 outpatient remote surveillance will advance postdischarge follow-up in the perioperative setting. there is growing impetus for surgeon-anesthesiologist to collaboratively participate in the "hospital-at-home" paradigm. 13, 14 improving effectiveness and efficiency through clinical pathways will also reduce hospitalacquired infections and other complications, thereby reducing length-of-stay-all of which are paramount as we define the "new normal" in perioperative care. therefore, current successful experience with remotely triaging and managing asymptomatic covid-19 patients can pave the way to widespread future rpm implementation in the postoperative discharge setting. anesthesiologists are well-trained to triage and to manage postsurgical patients using rpm technologies, and can thus potentially serve as reliable touchpoints for the 7-or 14-day transition of care visit in the outpatient setting. similar to ehr platforms, however, telehealth and rpm technologies have unresolved limitations. issues of data privacy and sharing, along with the shortcomings of digital infrastructures exist in these areas. we cannot ignore the digital divide and inequity of adoption that can occur along racial, ethnic, and socioeconomic lines, including limited access in underserved areas or among vulnerable patient populations. 15 public policy must support sustainable reimbursement models for virtual health visits. finally, robust outcomes research is necessary to assess the clinical effectiveness of these new technologies for patient care. while covid-19 certainly has convinced some previous skeptics of the relevance and safety of telehealth, o'reilly-shah et al 2 aptly remind us to identify and address its limitations. o'reilly-shah et al 2 reflect on the ethics and privacy challenges with data-sharing. 2 demonstrating and measuring improvement are equally relevant to the successful implementation and sustainability of any technological platform. creating a robust and consistent framework in these areas will ensure that the impact of technological advances on the quality, safety, and access to care are validly measured. certain types of technology, specifically, telehealth and telemedicine, have an assessment process recommended by national organizations, including the national quality forum (nqf), which could be extrapolated to measure the impact of other emerging technologies like predictive analytics and machine learning. the nqf has identified 3 factors most relevant to the adoption of technology: measuring its effect on quality outcomes, processes, and cost; selecting widely impactful quality measures; and using consistent definitions. 16 the nqf also has defined essential categories for measuring telehealth as a means of care delivery, including access to care, financial impact to patients and their care providers, patient and clinician experience, and effectiveness of clinical and operational systems. among these, the nqf suggested 6 priority areas: travel, timeliness of care, actionable information, impact of telehealth in providing evidence-based practices, patient empowerment, and care coordination. these nqf recommendations can serve as a guide in creating metrics for the impact of technology in anesthesiology and perioperative medicine. using the quality domain as a framework to monitor the outcomes, access, and consistency of innovative technologies also has implications for how these modalities can be included in payment systems. for instance, the nqf has suggested incorporating telehealth and telemedicine into the merit-based incentive payment system (mips) with respect to providing expanded practice access and encouraging population health management. each of the 9 mips improvement activity (ia) subcategories can be used to measure the impact of technology in anesthesiology and perioperative medicine ( table 2) . while the covid-19 pandemic accelerated technological innovation and facilitated easing of existing regulations for clinicians and federal technological oversight, it does not absolve practitioners from thoughtful analysis of the impact of new technology on care delivery. we advocate using consistent quality and clinical outcome measures in evaluating any technological platform and suggest how these can be easily applied to anesthesiology and perioperative medicine. establishing a uniform framework will ensure addressing the ethical and health equity implications of technology as we chart a new course after the initial covid-19 surge. in the inevitable post-covid pandemic era, what is the anesthesiologist's role in technology as our health care systems and other major stakeholders define the "new normal?" is this our opportunity to take a legitimate seat at the table of state and national discussions on value-based care and population health management strategies using our understanding of the continuum of care from the preoperative phase through the postdischarge phase? we will need to consider the optimal role of technology in addressing the currently accrued, and likely future ebbing and flowing "care debt" of deferred surgical treatment due to canceled elective procedures, as well as deferred medical conditions that worsen and require emergency procedural intervention. others have also suggested this window as a launching point for discussion on value-based care approaches in surgical and perioperative team-based settings. 13 working collaboratively will incorporate all members of a multidisciplinary team, including surgeons, anesthesiologists, nurses, physical therapists, and others, to embrace care delivery models that promote high value and efficient clinical care pathways and empower patients and caregivers through their coproduction and increased use of patient-reported outcomes. future innovation of technological platforms will allow decentralized care delivery through virtual pre-and postoperative appointments and the growth of home-based care and rehabilitation. as anesthesiologists, we are uniquely positioned to add meaningful value to this discussion. we are not only able to monitor and treat continuously changing physiologic parameters but also to adapt to ever-evolving environments. these abilities contribute new dimensions to future care delivery models. leveraging our specialty's strengths in technology, hemodynamic monitoring, and predictive analytics provides the platform to redesign and advance our profession and perioperative medicine after the initial covid-19 surge and beyond. the tipping point has arrived, technology will certainly advance, and adoption is sure to generate discontent. it is our duty and calling to embrace these frontiers and opportunities in the name of both invention and progress. e digital technology and covid-19 the covid-19 pandemic highlights shortcomings in u.s. healthcare informatics infrastructure: a call to action barriers to hospital electronic public health reporting and implications for the covid-19 pandemic rapid response to covid-19: health informatics support for outbreak management in an academic health system medicare telemedicine health care provider fact sheet telehealth transformation: covid-19 and the rise of virtual care virtually perfect? telemedicine for covid-19 covid-19 and health care's digital revolution covid-19 and telemedicine: immediate action required for maintaining healthcare providers well-being remote surveillance technologies: realizing the aim of right patient, right data, right time the value of remote monitoring for the covid-19 pandemic rapid implementation of a covid-19 remote patient monitoring program charting a roadmap for value-based surgery in the postpandemic era a different kind of perioperative surgical home: hospital at home after surgery addressing equity in telemedicine for chronic disease management during the covid-19 pandemic. catalyst non-issue content 1 creating a framework to support measure development for telehealth key: cord-295495-leyasj3d authors: wong, patrick; lim, wan yen; mok, may title: supraglottic airway–guided intubation during the covid-19 pandemic: a closed technique date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004951 sha: doc_id: 295495 cord_uid: leyasj3d nan to the editor d uring the coronavirus disease 2019 (covid-19) pandemic, minimizing aerosol generation and preventing health care worker's contamination are essential. 1 after failed intubation, supraglottic airway (sga) insertion, followed by flexible bronchoscopic intubation (fbi) via the sga (sga-guided fbi [sagfbi]), is one recommended option in the difficult airway society difficult intubation guidelines. 2, 3 we propose a potential "closed set up" version of sagfbi, which uses an ultrasound probe cover, to form a closed system to minimize aerosol contamination. a manikin demonstration of this "closed set up" (figure, panel a) is as follows. a disposable 3.8-mm ambu ascope (ambu a/s, baltorpbakken, ballerup, denmark) bronchoscope is preloaded with a 6.0-mm microlaryngeal tube. the bronchoscope handle has a connector that allows attachment of the tracheal tube. a civ-flex 610-637 ultrasound probe cover (civo, south kalon, ia) is used, which is a 91.5 × 8.9 cm sheath. the distal end of the probe cover is cut off so that it is open-ended at both ends. the bronchoscope is inserted into the probe cover until the whole insertion cord is covered. the proximal end of the probe cover is wrapped tightly against the bronchoscope handle, with the remaining loose cuff twisted into a plait. a small tegaderm film (3m deutschland gmbh; health care business, neuss, germany) tapes both the plait and proximal end of the probe cover to the handle, forming an airtight seal. approximately 10 cm proximal to the distal end of the probe cover, a small slit is created and the patient-end of a filter is inserted. the edges of the opening are taped around the filter, forming an airtight seal. a size 3 ambu auragain (ambu a/s, baltorpbakken) sga is inserted into the airway manikin. the distal end of the probe cover is pulled over the entrance of the auragain ventilation port and taped to form an airtight seal (figure, panel b) . the anesthetic circuit is attached to the filter, thus forming a closed system. with a gas flow of 6 l/min, and the adjustable pressure-limiting valve fully open, the "closed set up" gently fills up with 100% oxygen. sagfbi is performed in 3 steps 3 : (1) bronchoscope insertion into the trachea via the sga (figure, panel b and panel c), (2) railroading the tracheal tube over the bronchoscope and into the trachea (figure, panel d) , and (3) removal of the bronchoscope. the distal part of the probe cover becomes folded in a concertina-like manner, which needs to be intermittently straightened out. the filter is attached to the tracheal tube to complete intubation (figure, panel e) . the probe cover is carefully detached from the filter and sga. the bronchoscope and probe cover are then carefully discarded together as a single unit. there are various advantages to performing "closed" sagfbi in a covid-19 patient. first, the "closed set up" minimizes aerosolization. second, intubation remains "closed" throughout, that is, from insertion of the bronchoscope into the sga and the patient's airway until attachment of the anesthetic circuit to the tracheal tube, unlike other intubation techniques. third, 100% oxygen can be delivered to the patient by the anesthetic circuit via the filter (figure, panel b ). in addition, ventilation with low airway pressures in a correctly positioned sga will minimize leakage from the nose and mouth. as proposed by cook, 4 we suggest a 3-stage testing of this idea: (1) bench test on manikin using dye to identify aerosolization, (2) a rigorous human pilot study to test safety and effectiveness, and (3) a randomized controlled trial comparing it with standard "open" sagfbi. consensus guidelines for managing the airway in patients with covid-19 difficult airway society intubation guidelines working group. difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review novel airway devices: spoilt for choice? airtight seals are made by taping the proximal end of the probe cover and plait and taping the filter inserted near the distal end. the distal end is cut to allow later attachment to the supraglottic airway. b and c, intubation with visualization of the inside of the ventilation port and the vocal cords, respectively. the "closed set up key: cord-288569-sitxa2ul authors: smereka, jacek; ruetzler, kurt; szarpak, lukasz; filipiak, krzysztof jerzy; jaguszewski, milosz title: role of mask/respirator protection against sars-cov-2 date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004873 sha: doc_id: 288569 cord_uid: sitxa2ul nan to the editor s ince its outbreak on december 31, 2019, in wuhan, a central city in china, coronavirus disease 2019 (covid-19) has now spread to almost all countries in the world. it has been declared a pandemic, and it has infected over 1,041,126 people in a very short time, with 55,132 deaths as of april 3, 2020. wearing masks/respirators and practicing self-isolation at home have been recommended as guidelines for the public. however, the problem is the number of cases among medical personnel. interestingly, a higher risk of infection was noticed in male professionals. 1 there are currently many types of masks/respirators available, ranging from simple surgical masks designed to protect wearers from microorganism transmission and fit loosely to the user's face, through n95 masks used to prevent users from inhaling small airborne particles. these must fit tightly to the user's face. 2 masks differ primarily in their maximum internal leakage rate limit. surgical masks are designed to protect against droplets or particles with a diameter of >100 μm, whereas severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus is essentially spherical, albeit slightly pleomorphic, with a diameter of 60-140 nm and 100 times smaller than the pore diameter. thus, surgical masks cannot prevent inhalation of small airborne particles; however, both can protect users from large droplets and sprays. 3, 4 the pn-en 149:2001 standard defines 3 protection classes for half masks: filtering face piece 1 (ffp1), filtering face piece 2 (ffp2), and filtering face piece 3 (ffp3). the maximum internal leakage limit is 25% for ffp1, 11% for ffp2, and 5% for ffp3. class ffp1 masks retain about 80% of particles smaller than 2 μm, ffp2 ones retain 94% of particles smaller than 0.5 μm, and ffp3 ones retain 99.95% of particles smaller than 0.5 μm (table) . at the moment, we may meet divergent recommendations for the use of masks. while the centers for disease control and prevention recommend the use of masks in low-risk and high-risk situations, the world health organization advises applying masks in lowrisk situations and respirators in high-risk situations. long et al 5 conclude in their meta-analysis that the use of n95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza. they suggest that n95 respirators should not be recommended for the general public and non-high-risk medical staff who are not in close contact with influenza patients or suspected patients. the potential of face masks to reduce the spread of respiratory infections could be useful. wang et al 1 indicated that 10 of 213 medical professionals with no mask were infected by covid-19 as compared with 0 of 278 wearing n95 respirators. it is also worth noting that the respirator increases resistance to inhalation. the longer they are used, the more difficult breathing becomes because of more absorbed dust. what is more, the effectiveness decreases with the increase of carbon dioxide and water vapor between the respirator and face (the socalled dead space). the concentration of carbon dioxide in the dead space increases with each subsequent exhalation. therefore, masks should be replaced frequently. additionally, to improve the comfort of use, masks use 1-way exhalation valves, which accelerate the circulation of gases. 6 to conclude, the use of protective masks can and should be the first protection against sars-cov-2 transmission to medical personnel. medical personnel should use class ffp3 masks. additionally, the application of visors to cover the entire face during contact with the patient is worth considering. association between 2019-ncov transmission and n95 respirator use comparison of performance of three different types of respiratory protection devices protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks a close shave? performance of p2/n95 respirators in health care workers with facial hair: results of the beards (adequate respiratory defences) study effectiveness of n95 respirators versus surgical masks against influenza: a systematic review and meta-analysis cloth masks versus medical masks for covid-19 key: cord-345610-rx1zmajl authors: boggs, steven d. title: calculate the covid-19 equation with the people’s energy as key variable date: 2020-04-22 journal: anesth analg doi: 10.1213/ane.0000000000004892 sha: doc_id: 345610 cord_uid: rx1zmajl nan to the editor m ascha et al 1 have made a very valuable contribution for those of us trying to determine optimal icu staffing systems as a consequence of the coronavirus disease 2019 (covid-19) pandemic. sophisticated simulations presented in their article guide optimal staffing in intensive care units. while conventional staffing allocations do not keep a cohort protected, staffing aligned with the pandemic's epidemiology does. we have considered a similar method to one the authors' advocate. besides "joint efforts from people all around the world," 2 it appears to be absolute key that leaders attend to the psychological and emotional well-being of our clinicians in addition to the physical well-being of our staffs "to protect health care workers better, to save more lives." 2 necessary protective measures interfere with the camaraderie that each of us tries to create at work. while literally getting-in-touch is a caring physician's "first language," 3 the interactions with our patients now through masks and with ppe create barriers which are new to them and to us. we can no longer lunch with colleagues, gather in groups, or have collective conferences. there is a heightened anxiety for both our personal welfare and the people with whom we work and the concern we might bring infections back to our families. speaking with other american chairs of anesthesiology, every department is facing the same issues. we must work to ensure that no member in our departments is "left behind." we need to be more vigilant for psychological signs of burnout, 4,5 inattention to proper use of ppe, and withdrawal from video participation in departmental functions. our department has created a buddy system with daily check-ins. the chairs with whom i speak maintain as "normal" an atmosphere within the department as possible and send communication updates to keep everyone informed of the latest pertinent news. people have only so much psychic energy, and it is important to allow them to focus on the critical tasks at hand and to minimize extraneous duties. 6 we must calculate the covid-19 equation with the people's energy as key variable in mind! staffing with disease-based epidemiologic indices may reduce shortage of intensive care unit staff during the covid-19 pandemic to protect healthcare workers better, to save more lives offline: touch-the first language burnout in anesthesiology: a call to action burnout in anesthesiology providers: shedding light on a global problem 3 tips to avoid wfh burnout key: cord-291137-09a3tblt authors: chow, jonathan h.; mazzeffi, michael a.; mccurdy, michael t. title: angiotensin ii for the treatment of covid-19–related vasodilatory shock date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004825 sha: doc_id: 291137 cord_uid: 09a3tblt nan ; ang-1 = angiotensin i; ang-2 = angiotensin ii; apache = acute physiology and chronic health evaluation; ards = acute respiratory distress syndrome; at 1 = angiotensin type 1; at 2 = angiotensin type 2; athos-3 = angiotensin ii for the treatment of high output shock; ci = confidence interval; covid-19 = coronavirus disease 2019; ecmo = extracorporeal membrane oxygenation; edhf = endotheliumderived hyperpolarizing factor; icu = intensive care unit; mas = mitochondrial assembly protein; no = nitric oxide; raas = renin-angiotensin-aldosterone system; rrt = renal replacement therapy; sars = severe acute respiratory syndrome c oronavirus disease 2019 (covid-19) first appeared in wuhan, china, in early december 2019. 1 since then, the world health organization has classified it as a pandemic and, as of april 16, 2020, 186 countries have reported over 2 million confirmed cases and 138,000 deaths. 2 in the cohort of patients with severe disease, 89.0% were hospitalized and 8.1% died. 1 in the subgroup of patients admitted to the intensive care unit (icu), required mechanical ventilation, or died from the disease, 11.9% required continuous renal replacement therapy (rrt), 13.4% developed septic shock, and 40.3% developed acute respiratory distress syndrome (ards). 1 given the high morbidity and mortality in this cohort, we must utilize medications that are already available today to alter the pathophysiology and clinical course of this disease. doing so may improve outcomes while awaiting the development of targeted antiviral therapies and vaccines. [3] [4] [5] [6] [7] ards increases alveolar-capillary barrier permeability, reduces surfactant production, amplifies cytokine and interleukin production, and increases the risk of septic shock, which all culminate in severe pulmonary endothelial damage. 8 because angiotensin-converting enzyme (ace) is also located on the pulmonary endothelium, these proinflammatory processes severely disrupt ace function. 9 ace is integral to the renin-angiotensin-aldosterone system (raas), which is one of the 3 physiologic pathways that function in concert with the arginine-vasopressin and sympathetic nervous systems to autoregulate hemodynamics in humans. 10 dysfunction in ace (hazard ratio 0.56; 95% confidence interval [ci], 0.36-0.83; p = .011) and raas (estimated fixed effect of renin 1292.0 and 1428.7, 95% ci, 34.7-1428.7; p = .03) has been associated with decreased survival in septic shock. 3, 11 without functional ace in covid-19-associated ards, angiotensin i (ang-1) cannot be hydrolyzed into angiotensin ii (ang-2), which contributes to hypotension via 4 distinct mechanisms. first, inadequate production of ang-2 directly leads to decreased angiotensin type 1 (at 1 ) receptor agonism (figure 1 ), leading to decreased vascular smooth muscle constriction, decreased free water and sodium reabsorption by the kidney, and decreased aldosterone, cortisol, and vasopressin release by the hypothalamicpituitary-adrenal axis. 9,10 second, it leads to excessive accumulation of ang-1, which is metabolized into angiotensin-(1-9) (ang-(1-9)) and angiotensin-(1-7) (ang-(1-7)) to agonize the vasodilatory mitochondrial assembly protein (mas) and angiotensin type 2 (at 2 ) receptors ( figure 2 ). 9 third, ang-(1-7) directly activates nitric oxide (no) synthase, stimulating production of no, another potent vasodilator. 12 fourth, it impairs ace-dependent hydrolysis of bradykinin into bradykinin-(1-7) and bradykinin(1) (2) (3) (4) (5) , which leads to excessive accumulation of bradykinin (figure 1) . 13 this vasodilatory substance agonizes b 2 receptors and causes release of prostacyclin, no, and endotheliumderived hyperpolarizing factor (edhf). 14 because of these changes, a strong physiologic rationale exists for utilizing exogenous ang-2 to treat covid-19-associated vasodilatory shock. exogenous ang-2 targets the raas by replacing depleted endogenous ang-2 stores and agonizing at 1 receptors to increase vascular tone. furthermore, by increasing renal perfusion and decreasing renin secretion, exogenous ang-2 decreases ang-1 production and mitigates secondary mas, at 2 , b 2 , no, and bradykinin-induced vasodilatation. 9 the angiotensin ii for the treatment of high output shock (athos-3) trial found that ang-2 was effective at increasing mean arterial pressure and decreasing background norepinephrine dose. 15 one study found that patients with vasodilatory shock who rapidly responded to exogenous ang-2, defined as the ability to down-titrate to a dose ≤5 ng/kg/min within 30 minutes of initiation, had significantly lower levels of baseline endogenous ang-2 (mean ang-2 128.3 ± 199.1 pg/ml rapid responders versus 420.8 ± 680.4 pg/ml nonrapid responders; p < .01) and subsequently had decreased 28-day mortality (41% for rapid responders versus 66% nonrapid responders; p < .001) than those who did not rapidly respond. 4 in addition, ang-2 was associated with decreased 28-day mortality in patients with an acute physiology and chronic health evaluation (apache) ii score >30 (51.8% mortality for ang-2 versus 70.8% for conventional vasopressors; p = .037) and in patients with acute kidney injury (aki) on rrt (47% mortality for ang-2 versus 70% for conventional vasopressors; p = .012). 5, 6 furthermore, ang-2-treated patients experienced an increased rate of liberation from rrt by day 7 (38% for ang-2 versus 15% for conventional vasopressors; p = .007) compared to those who only received conventional vasopressors. 6 with up to 11.9% of critically ill covid-19 patients requiring rrt and with the continued exponential increase in the number of covid-19 cases worldwide, a large number of patients might benefit from earlier ang-2 utilization. 1 although the physiologic effects of ang-2 on the raas are known, many questions remain. current evidence suggests that severe acute respiratory syndrome [sars]-cov-2, the virus that causes covid-19, binds to the angiotensin-converting enzyme 2 (ace2) receptor with 10-20 times the affinity of sars-cov, identified in 2003, and that ace2 is required for cell entry and viral replication. 16 exogenous ang-2 has been shown to downregulate ace2 by internalization and degradation in animal models and in vitro studies of human cells. 17, 18 it is unknown whether these downregulatory effects on ace2 and can modulate the rate of covid-19 cell entry and viral replication. viral load and ace2 enzyme activity should be measured in patients who receive ang-2 or other vasopressors to better characterize their effects in covid-19-infected patients. the disruption of ace function in ards and sepsis makes early exogenous ang-2 administration a physiologically rational choice for the treatment of covid-19-associated vasodilatory shock. with the anticipated widespread shortage of life-sustaining equipment such as ventilators, continuous rrt machines, and extracorporeal membrane oxygenation (ecmo) circuits, critical care personnel such as rrt-trained nurses, intensivists, and respiratory therapists, and hospital resources such as critical care beds, emergency department beds, and personal protective equipment, every single rrt-free, hypotension-free, ventilator-free, and icu-free day will matter. although there are no current figure 1 . normal function of ace. ace hydrolyzes ang-1 into ang-2, which then acts on at 1 receptors to cause vasoconstriction. ace is also required at 2 points in the hydrolysis of bradykinin into bradykinin-(1-7) and bradykinin(1) (2) (3) (4) (5) . ace indicates angiotensin-converting enzyme; ang-1, angiotensin i; ang-2, angiotensin ii; at 1 , angiotensin type 1. figure 2 . effect of ace dysfunction on metabolite accumulation. dysfunction in ace as a result of endothelial damage, ards, and septic shock prevents the hydrolysis of ang-1 to ang-2 from occurring. ang-1 accumulates, and the excess is metabolized into ang-(1-9) and ang-(1-7). ang-(1-7) leads to activation of nitric oxide synthase and agonism of at 2 , b 2 , and mas receptors, which all lead to vasodilatation. in addition, ace dysfunction prevents the degradation of bradykinin into bradykinin-(1-7) and bradykinin-(1-5), which results in an excessive accumulation of bradykinin and potent vasodilatation. the figure was created with motifolio toolkit (motifolio inc, ellicott city, md). ace indicates angiotensinconverting enzyme; ang-(1-7), angiotensin-(1-7); ang-(1-9), angiotensin-(1-9); ang-1, angiotensin i; ang-2, angiotensin ii; ards, acute respiratory distress syndrome; at 2 , angiotensin type 2; mas, mitochondrial assembly protein; raas, renin-angiotensin-aldosterone system. clinical characteristics of coronavirus disease 2019 in china world health organization. coronavirus disease (covid-19) outbreak angiotensin i and angiotensin ii concentrations and their ratio in catecholamine-resistant vasodilatory shock sensitivity to angiotensin ii dose in patients with vasodilatory shock: a prespecified analysis of the athos-3 trial effect of disease severity on survival in patients receiving angiotensin ii for vasodilatory shock athos-3) investigators. outcomes in patients with vasodilatory shock and renal replacement therapy treated with intravenous angiotensin ii baseline angiotensin levels and ace effects in patients with vasodilatory shock treated with angiotensin ii the acute respiratory distress syndrome angiotensin converting enzyme defects in shock: implications for future therapy reversal of vasodilatory shock: current perspectives on conventional, rescue, and emerging vasoactive agents for the treatment of shock renin as a marker of tissue-perfusion and prognosis in critically ill patients bradykinin, angiotensin-(1-7), and ace inhibitors: how do they interact? role of bradykinin in mediating vascular effects of angiotensin-converting enzyme inhibitors in humans angiotensin ii for the treatment of vasodilatory shock cryo-em structure of the 2019-ncov spike in the prefusion conformation angiotensin ii mediates angiotensin converting enzyme type 2 internalization and degradation through an angiotensin ii type i receptor-dependent mechanism angiotensin ii up-regulates angiotensin i-converting enzyme (ace), but down-regulates ace2 via the at1-erk/p38 map kinase pathway key: cord-273884-dm73zgt8 authors: ludwin, kobi; szarpak, lukasz; ruetzler, kurt; smereka, jacek; böttiger, bernd w.; jaguszewski, milosz; filipiak, krzysztof jerzy title: cardiopulmonary resuscitation in the prone position: a good option for patients with covid-19 date: 2020-06-16 journal: anesth analg doi: 10.1213/ane.0000000000005049 sha: doc_id: 273884 cord_uid: dm73zgt8 supplemental digital content is available in the text. to the editor p rone positioning of intubated patients suffering from pneumonia improves ventilation-perfusion matching, recruits collapsed alveoli, provides a more uniform distribution of tidal volume through improved chest wall mechanics, and may decrease mortality in more severely hypoxemic patients. guérin are at high risk for developing severe pneumonia and subsequent ards. prone positioning is therefore a common strategy in their intensive care as well. recent reports indicate based on multiple pathologies covid-19 patients are at higher risk for cardiac arrest. 2 immediate initiation of cardiopulmonary resuscitation (cpr), including chest compressions, are crucial but challenging when the patient is prone. performance of cpr in the prone position is uncommon, but there are several reports of cpr in patients in the prone position having spine surgery (supplemental digital content, table 1 , http://links. lww.com/aa/d134). a reasonable question is whether a prone patient with cardiac arrest be turned supine before initiating cpr or remain in the prone position. turning a patient is time-consuming, requires multiple individuals and therefore multiple exposures, and increases the risk for adverse events like endotracheal tube displacement and disconnection of arterial and venous lines. in the prone position, the proper hand positioning is important. kwon et al 3 reported that the largest left ventricular cross-sectional area is 0-2 vertebral segments below the inferior angle of the scapula in at least 86% of patients in patients positioned prone. two separate studies investigated the efficacy of cpr in the patients positioned prone. wei et al 4 reported that cpr in prone position compared to the supine position was associated with higher mean systolic blood pressure (sbp; 79 ± 20 vs 55 ± 20 mm hg) and higher diastolic blood pressure (dbp; 17 ± 10 and 13 ± 7 mm hg, respectively). the analysis indicates that in the prone position, sbp was statistically significantly higher than in supine position (mean difference [md] = 24.00; 95% ci, 5.79-42.21; p = .010), while in dbp, the difference was not statistically significant (md = 4.00; 95% ci, −3.65 to 11.65; p = .31). mazer et el 5 reported the advantage of prone position over the supine position in the context of sbp (72 vs 48 mm hg; p < .05; mean arterial pressure (46 vs 32 mm hg; p < .05) and dbp (34 vs 24 mm hg; p > .05). during cpr in prone position, endotracheal/tracheostomy tube dislodgement can occur and the patient may then need to be turned for intubation. injuries to ribs, spine, scapula, clavicles, or eyeballs and shoulder dislocation are possible. the effectiveness of cpr is affected by the depth of chest compressions and therefore it is still recommended to place the patient on a hard surface or to place a hard board under the patient. ards patients are placed in prone position for several hours, while covid-19 ards patients for even 12-18 hours or more. the prone position is also used in patients undergoing noninvasive ventilation, in spontaneously breathing nonintubated patients, for example, due to refractory hypoxemia in acute respiratory failure including lung transplantation. 6 in summary, cpr in the prone position seems to be a reliable method to provide cpr in patients positioned prone. proseva study group. prone positioning in severe acute respiratory distress syndrome in-hospital cardiac arrest outcomes among patients with covid-19 pneumonia in wuhan optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan cardiopulmonary resuscitation in prone position: a simplified method for outpatients reverse cpr: a pilot study of cpr in the prone position prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study key: cord-012459-tge08va0 authors: matthews, laura j.; o-connor, michael; chaggar, rajinder singh; vaughan, david title: airway alert bracelets: enhancing safety in the coronavirus disease 2019 era date: 2020-08-18 journal: anesth analg doi: 10.1213/ane.0000000000005165 sha: doc_id: 12459 cord_uid: tge08va0 nan to the editor a t our hospital, we have a high number of patients with sars-cov-2 requiring intubation. at the peak of the crisis, we were intubating almost 1 patient per hour. to manage these patients efficiently, teams of anesthetists intubate the patients where they are, most often in the emergency department, and then transfer them to the intensive care unit (icu). our records are electronic, but because of pressures of the current crisis, handover and documentation may not be as comprehensive or immediately accessible as usual. we are concerned that potential key information about patients with difficult airways can be missed. as mentioned in a recent letter to this publication by berkow and kanowitz, 1 patients treated for coronavirus disease (covid) on the icu are at a higher risk than normal for accidental extubation and therefore requiring emergency reintubation. this is due to a multitude of factors, including higher nursing ratios and that many of our patients require regular proning-a procedure where there is significant risk of accidental extubation. 2 for logistical reasons, patients are frequently moved, and a substantial number of our patients are transferred to other units for ongoing care. these actions make conventional "signs above the bed" unreliable as sole indicators of a difficult airway. emergency reintubation is usually a time critical procedure, often not allowing for a thorough review of the patient's notes. we have designed a medical alert bracelet, similar to a hospital name band, that is placed on any patient where nonstandard equipment (anything other than iview video laryngoscope [intersurgical, wokingham, england] plus bougie) was needed to secure the airway or where the person intubating experienced difficulty. the bracelets are stocked in our intubation bags and placed on the patient immediately after intubation if difficulty is encountered. they then remain on the patient's wrist for the duration of their icu stay and provide a visual alert of their difficult airway, regardless of the bed space or even hospital if they are transferred for ongoing care (figure) . the presence of this bracelet on a patient prompts a review of the electronic intubation notes before undertaking any procedure where the airway could be "at risk," and appropriate measures to be put in place-for example, a senior anesthetist with the relevant equipment present when airway alert patients are proned or deproned. in the event of an airway emergency, such as accidental extubation, the presence of the bracelet would immediately highlight the need for the rapid attendance of the most senior skilled airway physician with appropriate equipment for managing a difficult airway. with the high numbers of tracheostomies performed to aid ventilatory weaning we have also devised similar bracelets for patients with new tracheostomies, detailing the type of tracheostomy and date performed. these alert bracelets have been well received within the department and are a simple way to enhance the safe care of intubated patients where standard safety measures may not be possible or reliable. while we are aware of medical alert bracelets being used to indicate patients with chronic medical conditions in the community, 3 we are not aware of their use in the acute setting to maintain safety in a pressured environment. covid-19 putting patients at risk of unplanned extubation and airway providers at increased risk of contamination dod covid-19 practice management guide; clinical management of covid-19 airway alert bracelets: enhancing safety in the coronavirus disease 2019 era figure. disposable single use alert bracelets for patients with difficult to manage airways and new tracheostomies key: cord-258071-amkfz940 authors: brown, sarah; patrao, fiona; verma, shilpa; lean, alexa; flack, sean; polaner, david title: barrier system for airway management of covid-19 patients date: 2020-04-22 journal: anesth analg doi: 10.1213/ane.0000000000004876 sha: doc_id: 258071 cord_uid: amkfz940 nan to the editor a irway management of patients with coronavirus disease 2019 (covid-19) poses significant risk to involved staff because of the aerosolizing nature of airway interventions. 1 aerosolization can occur during face mask and supraglottic airway ventilation, intubation, extubation, and cardiopulmonary resuscitation. 2 these activities require increased precautions and containment of viral respiratory particles. it has been demonstrated that a containment system can limit the spray of a significant portion of respiratory particles during a simulated cough or extubation. 3, 4 we applaud innovation of new protective barrier enclosures to protect the laryngoscopist and the room during airway interventions. when selecting such a barrier device, one should consider the importance of access to the airway, containment of aerosolization, time required to set up the device for patient use, and patient tolerance of the device. one should also be cognizant of the cost and necessary time for production and deployment of the device. some barrier devices, while superior at containing aerosolization, unfortunately restrict the laryngoscopist's hand movements and would require abandoning a laryngoscopy attempt to remove the barrier if it proved too cumbersome. in some cases, it is important to allow a second pair of hands to access the patient's airway to aid in the intubation should it prove difficult (providing lip traction, assisting with the stylet, etc). this may not be possible with some barrier devices. in addition, an ideal device could be set up quickly for patient use and not cause patient agitation, which is particularly important in the pediatric population. we propose an inexpensive clear plastic drape on bag barrier system made from materials that are ubiquitous in the hospital (figure) . the barrier can be easily removed even mid-laryngoscopy attempt. this drape www.anesthesia-analgesia.org letters to the editor chest is similar to application of electrocardiogram leads. the total cost of disposable materials for this system is $1.44. there is nothing restricting access to the airway from under the drape, so one could easily assist the laryngoscopist or remove the drape during laryngoscopy if required. after intubation is performed and endotracheal tube secured, the clear plastic drape can be tucked into the drawstring bag, which now contains the contaminated airway space for the duration of the case. the patient could be later extubated under the clear drape, and the drape can then be removed and placed in the drawstring bag along with disposable airway equipment such as the suction catheter and stylet. the drawstring bag is then cinched closed, containing the contaminated drape and head of bed space, and can be disposed. we also recommend sealing used laryngoscopy equipment in a ziplock biohazard bag (thermo fisher scientific, waltham, ma). this plastic drape on bag system is being trialed at our hospital in the operating rooms and in the emergency department and intensive care unit. in simulated settings at our institution, it provides an added layer of protection from spray of contaminated viral particles for personnel present at airway procedures. the system contains the most contaminated surface surrounding the patient's airway and can easily be disposed of to maintain a cleaner hospital environment. we found that the best use of this device is for nonemergent intubation of a tolerant or sedated patient. viral dynamics in mild and severe cases of covid-19 centers of disease control and prevention barrier enclosure during endotracheal intubation clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for covid-19 key: cord-280794-k591vqji authors: bauer, melissa e.; chiware, ruth; pancaro, carlo title: neuraxial procedures in covid-19–positive parturients: a review of current reports date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004831 sha: doc_id: 280794 cord_uid: k591vqji nan to the editor c oronavirus disease 2019 (covid-19) in pregnancy presents a unique challenge given the limited data on anesthetic management. other viral diseases, such as h1n1 influenza and severe acute respiratory syndrome (sars), have been associated with severe respiratory compromise in pregnancy. because anesthesiologists must take into account the risk of meningitis or encephalitis associated with neuraxial procedures in the setting of untreated viremia, we reviewed publications reporting outcomes in covid-19-positive pregnant women in the current pandemic in an attempt to address this concern. a literature search for all articles reporting confirmed covid-19 infection at the time of delivery revealed 4 publications reporting 14 cases admitted between january 20, 2020 and february 6, 2020. in reports with no information about neuraxial use, authors were contacted via e-mail to gather that information (13 of 14). there were no reported neurologic sequelae after neuraxial procedures in any of these cases. [1] [2] [3] [4] case details are reported in the table. thirteen patients (93%) underwent cesarean delivery; 6 (43%) were preterm (<37 weeks of gestation). fever was present in 10 (71%) patients and 2 (14%) patients were treated with antiviral medication before the neuraxial procedure. computed tomography or chest x-ray evidence of pneumonia was reported in all patients before delivery. clinical severity in symptoms was not always reported, but ranged from resolution of respiratory symptoms to noninvasive ventilation at the time of cesarean delivery. white blood cell (wbc) count levels were not elevated in 13 (86%) patients. one patient presented with a wbc count of 8.7 × 10 6 /l and received daily methylprednisolone for inflammation. her wbc count subsequently increased to 22.9 × 10 6 /l. 1 thrombocytopenia was reported in 2 pregnant patients without preeclampsia with the nadir being platelet counts of 81,000 and 91,000 × 10 6 /l, respectively. 1,2 a case series of 138 covid-19-positive nonpregnant patients reported about one-third of patients had thrombocytopenia (<150,000 × 10 6 /l) regardless of severity of illness. 5 assessing whether a parturient with covid-19 is suitable for neuraxial procedures should focus on neuraxial procedures in covid-19-positive parturients: a review of current reports the risks of general anesthesia compared with neuraxial anesthesia. labor epidural procedures should also be considered as a means to avoid general anesthesia because the in-situ catheter allows extension for cesarean delivery anesthesia should an urgent cesarean delivery be needed. in general, the risk of causing meningitis or encephalitis is extremely low with neuraxial procedures, even in infected patients. febrile patients with altered mental status commonly undergo diagnostic lumbar punctures. it is thought that patients who subsequently developed meningitis following lumbar puncture were early in the progression of the disease (before cerebrospinal fluid [csf] evidence of disease) or the meningitis was due to the pathogenic nature of the specific bacteria rather than seeding of the bacteria in the subarachnoid space. 6 covid-19 patients with hypoxia and concomitant physiologically decreased functional residual capacity from pregnancy will be likely to become more hypoxic, develop further atelectasis with intubation and mechanical ventilation, and possibly require postoperative critical care admission. before performing a neuraxial procedure in these patients, it would be advisable to review a recent platelet count given that one-third of patients with covid-19 infection have been reported to have thrombocytopenia compared with 7%-12% of patients during pregnancy alone. 7 in pregnant women, a platelet count of 70,000 × 10 6 /l has a low risk for spinal epidural hematoma, and lower levels should be considered in cases such as these with a high risk for respiratory compromise with general anesthesia. 8 although 2 of the 14 cases were reported to have received antiviral treatment before the neuraxial procedure, there is no currently accepted antiviral medication known to be effective for covid-19, according to the centers for disease control and prevention. in conclusion, we believe the real risk of general anesthesia outweighs the theoretical risk of causing meningitis/encephalitis by performing neuraxial procedures, and we therefore recommend performing neuraxial procedures in parturients with covid-19 unless otherwise contraindicated. lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, china. emerg infect dis j coronavirus disease 2019 (covid-19) during pregnancy: a case series clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records a case of 2019 novel coronavirus in a pregnant woman with preterm delivery clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan risk factors for development of bacterial meningitis among children with occult bacteremia american college of obstetricians and gynecologists' committee on practice bulletins, turrentine m. acog practice bulletin no. 207: thrombocytopenia in pregnancy multicenter perioperative outcomes group investigators. risk of epidural hematoma after neuraxial techniques in thrombocytopenic parturients: a report from the multicenter perioperative outcomes group key: cord-302112-l74s05s0 authors: laosuwan, prok; earsakul, athitarn; pannangpetch, patt; sereeyotin, jariya title: acrylic box versus plastic sheet covering on droplet dispersal during extubation in covid-19 patients date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004937 sha: doc_id: 302112 cord_uid: l74s05s0 nan to the editor a lthough the main mechanism of coronavirus disease (covid-19) transmission is droplet spreading, there are concerns about aerosolgenerating procedures such as extubation. 1 there are some suggestions from around the world proposing the placement of large transparent plastic sheets over patients' faces to limit the contamination area. 2, 3 therefore, we compared the effectiveness and spreading patterns of acrylic boxes and plastic sheets as protective barriers compared to noncoverage technique under fluorescent condition. to simulate coughing during tracheal extubation, we intubated the airway of a manikin with an endotracheal tube, size 7.0, with 21 cm depth. we designed a droplet generating device that would simulate a cough with an estimated velocity of 4-10 m/s. a tubing was then connected to the pressure generator and the tip of the nozzle was fixated at the midline in the oral cavity. one milliliter of fluorescent alcohol was then injected through the device as a simulated mass of secretion and droplets. three different configurations of clear acrylic boxes were used and are illustrated in the supplemental digital content, figure 1 , http://links.lww.com/aa/d105. the transparent plastic sheet used was 115 × 100 cm. the dispersion of droplets was counted by the number of stained squares only outside the boxes and not as the number of glow spots in each square. we recorded from 3 areas: (a) around the manikin, (b) on the chest of the manikin, and (c) on the anesthesia personnel's gown and face shield. to systematically document the dispersion outside the boxes, each area was divided differently into columns and rows. a total of 300 measurement squares measuring 5 × 5 cm were created. the incidence of self-contamination was counted and recorded. each technique was simulated and recorded for 5 consecutive times under fluorescent condition in a darkened research room. we demonstrated the differences of overall droplet dispersion between 3 acrylic box models (3.3%-19.0%), plastic sheet (2.8%), and noncoverage technique (26.3%) during tracheal extubation. all acrylic boxes showed no contamination on anesthesia personnel. the plastic sheet caused contamination both on the chest and abdomen of anesthesia personnel. regardless of the technique, the contamination area was more prominent on the right side of the table. using any box during extubation demonstrated no contamination along the upper border of the table. the spreading pattern of all techniques is shown in the figure, panels a-e. the advantages of using an acrylic box to reduce droplet dispersal are the ease of use and its rigid structure which limits the spreading. 4 however, higher cost and cleaning procedures can be disadvantageous. moreover, using different models resulted in different protective outcomes as we proposed. this could be due to the individual design of each box (eg, the top [slope or flat]), the presence of a side-door opening and awning, and hand slots. the height of the box might take part in the contamination area as the droplet dispersion may rebound to the surroundings after striking the top. the slope top can also affect the contamination area. uncontrollable dispersed flow against the slope top might cause the rebounding of secretion to the hand slots. the side door may cause more contamination if it is opened for airway management assistance. therefore, we recommend to open the door as necessary for shortest time as possible. also, if the box is completely wrapped with plastic sheet at both hand slots and around caudalopening space, the risk of contamination should be diminished as it becomes a nearly closed system. there are several concerns when using an acrylic box during airway intervention. first, the cleaning methods are still inconclusive, leading to crosscontamination. second, the hand slots limit hand movement for complicated airway procedures. thus, suspected difficult airway cases should be evaluated cautiously and personnel should be adequately trained before use. third, if the patient is agitated or not cooperative, there is a risk of minor trauma. using a plastic sheet also resulted in less contamination in the manikin. 5 the advantages of a plastic sheet are disposability, lower cost, and less restriction to hand movement. 6 however, we demonstrated selfcontamination toward the extubator. although we used only 1 ml of fluorescent fluid, the cough flow spread varied widely under the plastic sheet and toward the opposite side of the extubation attendant which was similar to how lava flows from volcanic eruptions (figure, panels f) . furthermore, improper discarding of the plastic cover sheet can lead to crosscontamination of the health care workers. therefore, the discussed protective tools are helpful in decreasing contamination from droplet dispersion. supplemental digital content is available for this article. direct url citations appear in the printed text and are provided in the html and pdf versions of this article on the journal's website (www.anesthesia-analgesia.org). perioperative management of patients infected with the novel coronavirus: recommendation from the joint task force of the chinese society of anesthesiology and the chinese association of anesthesiologists anaesthesia and caring for patients during the covid-19 outbreak guidelines for patients with covid-19 suspected or confirmed infection in the perioperative environment barrier enclosure during endotracheal intubation clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for covid-19 barrier system for airway management of covid-19 patients the droplet spreading patterns of panels (a), (b), (c), transparent plastic sheet (d), and noncoverage technique (e). f, the volcano eruption-like effect and the uncontrollable lava flow under the sheet we appreciate the contributions to this study from the following: administrators of simulation and cardiopulmonary resuscitation center (cpr) center of king chulalongkorn memorial hospital, who gave their time and effort, and paulo r. c. dalpian, phd, for proofreading this document. key: cord-305066-g042y51w authors: abd-elsayed, alaa; karri, jay title: utility of substandard face mask options for health care workers during the covid-19 pandemic date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004841 sha: doc_id: 305066 cord_uid: g042y51w nan w ith the emergence and exponential spread of coronavirus disease 2019 (covid-19), the utility and recommendations of face masks and respirators (ie, n95 masks) for various populations have come into question. [1] [2] [3] despite the world health organization (who) recommendation that the use of face masks is only for those caring for individuals with suspected covid-19, or for those with active coughing or sneezing, inappropriate purchasing and use by the general public have led to a critically diminishing supply of face masks and respirators. 3, 4 this limitation in supply is especially concerning, given the exponential increase in cases of disease from severe acute respiratory syndrome coronavirus 2 (sars-cov-2) worldwide. health care workers (hcws), notably those in more impoverished countries, continue to be at particular risk and are faced with using substandard options. [4] [5] [6] the us centers for disease control and prevention (cdc) has suggested that the use of substandard optionsincluding surgical masks, cloth masks, and extended use or reuse of respirators-can be considered, with exercised caution. in this commentary, we attempt to characterize the utility of and provide considerations for the use of these substandard face mask options by hcws during the covid-19 pandemic. the sars-cov-2 is a respiratory virus largely spread via droplet and possibly also airborne contact. 1-6 viral spread largely occurs via exposure of the nasopharyngeal or oropharyngeal mucosa to microdroplets expelled from coughing and/or sneezing by infected individuals. thus, those persons wearing standard surgical face masks are still at risk for droplet exposure via the lateral, unsealed portions of the face mask. 4-6 on the contrary, standard respirators approved by the national institute of occupational safety and health (niosh), namely n95 masks, are fit and seal tested to ensure filtration of at least 95% of airborne droplets. few studies characterizing efficacy of cloth masks exist. to a lesser extent, viral transmission occurs by spread of microdroplets from contaminated surfaces onto the face, nasopharyngeal, and oropharyngeal mucosa. therefore, most mask options are intended for single use only, and must be carefully doffed and disposed. in the setting of a pandemic, the reuse of respirators is also being entertained and warrants careful consideration. fit-and seal-tested respirators are considered the gold standard for personal protective equipment against droplet-transmitted infections. 5, 6 the filtration efficacy of these respirators varies by manufacturer, but is also largely dependent on the size of the penetrating particles. for context, the sars-cov-2 virion spherical diameter is reported to be approximately 125 nm, as estimated by cryo-electron tomography and cryo-electron microscopy. 7,8 qian et al 9 report an approximate 99.5% filtration efficacy of n95 respirators for particles 750 nm in size. this filtration efficacy decreases to 95% for particles 100-300 nm in size. n95 respirators are sold by manufacturers only when a 95% filtration efficacy standard per niosh requirement is met. similarly, n99 and n100 respirators correspond to 99% and 99.7% filtration efficacies for particles 100-300 nm in size, respectively. 10, 11 on the contrary, surgical face masks are not required to meet similar filtration efficacy standards to be sold. depending on manufacturers and the use of niosh filtration standards, surgical face masks have widely reported filtration efficacies ranging from <10% to ≤90%. aside from filtration efficacy, risk reduction associated with surgical masks is heavily reliant on good fit and facial seal. macintyre et al 12 previously reported that the adherent use of surgical face masks or respirators was superior to not using either form of protection in preventing adults from contracting influenza in affected households. there was no appreciable difference in risk reduction between surgical face masks and respirators (n95 face masks). interestingly, the benefit of either mask was significantly dependent on adherence of face mask use. moreover, aiello et al 13 observed that the risk reduction of viral contraction with surgical face mask use was significant with concomitant hand washing practices. such findings collectively suggest that the adherent use of even suboptimal face masks, along with recommended hand washing practices, may provide meaningful decrement in the risk of contracting respiratory viral illnesses. many resource-depleted settings are considering the utility of cloth masks, which are often reusable with washing. cloth masks have been used historically, with variable reports of benefit. 14, 15 the best evidence exploring cloth masks comes from a randomized trial in vietnam that compared the risk of hcws contracting respiratory viral illnesses using "medical face masks" (presumably equivalent to standard surgical masks) with cloth masks, which were described as 2-layer cotton masks. 14 briefly, they found that hcws in the cloth mask intervention arm had a relative risk of 13.0, in reference to those persons in the medical face mask group, for contracting influenza-like illnesses. the authors conclude that cloth masks should not be used when medical face masks are an option. it should be noted that cloth masks are widely varied and provide varying potential benefit dependent on fabric type, construction, number of layers, and reuse, and cleaning practices. 16 while cloth masks are often manufactured and used in asian countries, the utility of these cloth masks is also being considered for use in other resource-depleted settings. prototypes and benefit of cloth masks have been previously published. 1416 rengasamy et al 16 reported that pure cotton, pure polyester, and cotton/polyester blend cloth masks were all significantly inferior to respirators in filtering out aerosol particles in the 100-to 300-nm range. they were unable to report superiority of any given fabric, but suggested that cloth masks may be comparable to some standard surgical masks, and the efficacy of cloth masks can be improved with appropriate face seal and fit. in the covid-19 pandemic, the chinese state council reports that masks are not necessary for persons at very low risk of infection, but that nonmedical masks, such as cloth masks, may be used. 3 cdc reports that cloth masks may be a necessary last-resort option only when respirators and surgical masks are unavailable. 4 the us cdc defines extended use as the use of a single respirator across multiple, close-contact patient encounters without doffing and replacing in between patients. 5 it defines reuse as the repeat donning and doffing of the same respirator across multiple, closecontact patient encounters. both options are inherently substandard to the single-use indications for conventional respirators. 4, 5 the risks associated with these options are that of viral transmission via self-inoculation and direct contact after touching a contaminated respirator. infectious spread with repeat respirator use is not limited to respirator reuse, but also to extended use. one study found that nurses touched their respirators an average of 25 times during a shift. 17 . cdc suggests that while extended-use practices may not decrease respiratory protection, disposal of used respirators should be considered if they are structurally compromised, directly exposed to bodily fluids, in close contact with infected patients, or after scenarios of significant aerosol production (ie, intubations). 5 the use of face shields is recommended to reduce surface contamination of the respirator. in addition, cdc recommends proper doffing and donning protocol, including the use of clean gloves to ensure proper seal and fit after donning to ensure respirator integrity and respiratory prevention with reuse. with the exponential spread of covid-19, hcws are faced with a diminishing supply of respirators (n95 masks). hcws, especially those in more impoverished areas of the world, are faced with using substandard options such as surgical face masks, cloth masks, and even extended use or reuse of respirators. surgical masks afford varying degrees of respiratory protection, which can be optimized with proper face seal and fit and with proper handwashing techniques. cloth masks carry unclear and variable benefit, and may be a last-resort option only when respirators and surgical masks are unavailable. defining the epidemiology of covid-19-studies needed supporting the health care workforce during the covid-19 global epidemic rational use of face masks in the covid-19 pandemic coronavirus disease (covid-19) advice for the public: when and how to use masks strategies for optimizing the supply of n95 respirators: crisis/alternate strategies recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings cryo-electron tomography of mouse hepatitis virus: insights into the structure of the coronavirion supramolecular architecture of severe acute respiratory syndrome coronavirus revealed by electron cryomicroscopy performance of n95 respirators: filtration efficiency for airborne microbial and inert particles respiratory performance offered by n95 respirators and surgical masks: human subject evaluation with nacl aerosol representing bacterial and viral particle size range do n95 respirators provide 95% protection level against airborne viruses, and how adequate are surgical masks? face mask use and control of respiratory virus transmission in households facemasks, hand hygiene, and influenza among young adults: a randomized intervention trial a cluster randomised trial of cloth masks compared with medical masks in healthcare workers use of cloth masks in the practice of infection control-evidence and policy gaps simple respiratory protection-evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses key: cord-273737-t6j3leec authors: poeran, jashvant; zhong, haoyan; wilson, lauren; liu, jiabin; memtsoudis, stavros g. title: cancellation of elective surgery and intensive care unit capacity in new york state: a retrospective cohort analysis date: 2020-06-30 journal: anesth analg doi: 10.1213/ane.0000000000005083 sha: doc_id: 273737 cord_uid: t6j3leec background: in response to the coronavirus disease 2019 (covid-19) pandemic, new york state ordered the suspension of all elective surgeries to increase intensive care unit (icu) bed capacity. yet the potential impact of suspending elective surgery on icu bed capacity is unclear. methods: we retrospectively reviewed 5 years of new york state data on icu usage. descriptions of icu utilization and mechanical ventilation were stratified by admission type (elective surgery, emergent/urgent/trauma surgery, and medical admissions) and by geographic location (new york metropolitan region versus the rest of new york state). data are presented as absolute numbers and percentages and all adult and pediatric icu patients were included. results: overall, icu admissions in new york state were seen in 10.1% of all hospitalizations (n = 1,232,986/n = 12,251,617) and remained stable over a 5-year period from 2011 to 2015. among n = 1,232,986 icu stays, sources of icu admission included elective surgery (13.4%, n = 165,365), emergent/urgent admissions/trauma surgery (28.0%, n = 345,094), and medical admissions (58.6%, n = 722,527). ventilator utilization was seen in 26.3% (n = 323,789/n = 1232,986) of all icu patients of which 6.4% (n = 20,652), 32.8% (n = 106,186), and 60.8% (n = 196,951) was for patients from elective, emergent, and medical admissions, respectively. new york city holds the majority of icu bed capacity (70.0%; n = 2496/n = 3566) in new york state. conclusions: patients undergoing elective surgery comprised a small fraction of icu bed and mechanical ventilation use in new york state. suspension of elective surgeries in response to the covid-19 pandemic may thus have a minor impact on icu capacity when compared to other sources of icu admission such as emergent/urgent admissions/trauma surgery and medical admissions. more study is needed to better understand how best to maximize icu capacity for pandemics requiring heavy use of critical care resources. icu bed and ventilator capacity, however, is not well studied. we reviewed new york statewide planning and research cooperative system (sparcs) data from 2011 to 2015 to estimate the effect of statewide suspension of elective surgeries on icu bed and ventilator usage. to assess the potential impact on new york city (nyc), we evaluated how nyc-the current epicenter of the covid-19 outbreak-related to the rest of nys with respect to changes in elective surgery and icu/ventilator capacity. this study was approved by the institutional review board of hospital for special surgery (2016-436). the requirement for written informed consent was waived given the deidentified nature of the data. patient-level data were extracted from the new york sparcs dataset (2011-2015), which includes patient-level and billing data for all inpatient and outpatient visits in nys. we included all adult and pediatric icu admissions and excluded cases classified as "newborn" or "neonatal" icu admissions, those with missing date of admission, and patients with hiv infection or who had an abortion (due to withholding of data on these patients by nys). icu and mechanical ventilation were defined using icu-specific billing codes 1 and international classification of diseases, ninth edition (icd-9) codes 93.9x and 96.7x. mechanical ventilation was further classified into invasive/noninvasive and duration (≥96 and <96 hours of consecutive invasive ventilation). the source of icu admission was categorized as (1) elective surgery, (2) emergent/urgent/trauma surgery admissions, and (3) medical admissions. surgical/medical cases were differentiated based on icd-9-clinical modifications surgical flag software. 2 type of admission (elective, emergent, trauma, and urgent) is a variable coded in the sparcs database. additional study variables included geographic region (nyc metropolitan area-defined as nyc, long island, and the mid-and lower hudson valley counties-compared to the rest of nys) and year. nys hospital-level data 3 included the number of icu beds by hospital (categorized by small, 1-5 beds/medium, 6-15 beds/large, 16-30 beds/very large, >30 beds), and types of icu. overall, 157 nys hospitals have a permanent icu representing a total number of 4266 icu beds (700 reserved for neonates, 380 pediatric, and 3186 adult icu beds). all analyses were conducted using sas version 9.4 (sas institute, cary, nc). results were reported as case number and percentage, stratified by year, source of icu admission, and geographic region. because sparcs does not provide icu length of stay data, we used the most recent estimate of an average of 3.8 days spent in the icu, as published by the society of critical care medicine, 4 to estimate annual total icu days in this pre-covid-19 period (across 3566 pediatric and adult icus). as a sensitivity analysis, we also calculated a range of 20% shorter or longer average icu length of stay. number of total icu days was subgrouped by source of admission to allow for a theoretical estimation of the number of covid-19related icu stays to be gained with the elimination of icu days related to elective surgery. an icu length of stay of 10.5 days was applied for this estimation based on data from california and washington state. 5 a total of 1,235,517 icu admissions were identified from 2011 to 2015 in nys. n = 693 cases were excluded because of missing inpatient admission date, and 1838 newborn cases were excluded. for our analysis, 1,232,986 cases were included, averaging 246,597 (n = 1,232,986/5) per year. this represented 10.1% of total hospital admissions over the study period (n = 1,232,986/n = 12,251,617) which remained stable over time (figure) . average icu occupancy rate was 72.0% (with a range of 57.6%-86.4% using a 20% variation in assumed average icu length of stay). overall, 13.4% of icu admissions were attributed to elective surgery, versus 28.0% for emergent/urgent/trauma surgery and 58.6% for medical reasons (table 1) among all icu admissions, 26.3% (n = 323,789/ n = 1,232,986) of patients required mechanical ventilation. the majority (60.8%) of ventilated patients were medical icu admissions while 6.4% represented patients admitted to the icu after elective surgery. emergent/urgent/trauma surgery-related icu admissions were most likely (51.2%) to require prolonged (ie, ≥96 hours) of invasive ventilation ( table 2) . nyc had twice as many icu beds and admissions as the rest of nys (table 3) . of all ventilated patients in nys, 70.0% were located in the nyc metropolitan area. this imbalance in icu volume and use of mechanical ventilation was particularly evident for emergent/urgent/trauma surgery-related icu admissions (n = 247,998 in nyc compared to n = 97,096 admissions in nys) and the number of high icu volume hospitals. in nyc, 221,970 patients required an icu stay with mechanical ventilation (table 3) ; 12,726 of those patients were admitted after elective surgery (12,726/221,970 = 5.7%), versus emergent/urgent/trauma surgery (n = 75,334) and medical reasons (n=133,910). in comparison, in nys, 7.8% (7926/101,067) of patients required mechanical ventilation in the icu. in this 5-year retrospective review of the new york sparcs database, we found that only 13% of icu admissions represented an admission after elective surgery. in contrast, more than twice as many patients requiring an icu were admitted after emergent/ urgent/trauma surgery while the bulk of icu admissions were for medical reasons. elective surgeries played an even smaller role (6%) in terms of mechanical ventilation requirements while this was 33% and 61% for icu admissions related to emergent/urgent/ trauma surgery and medical reasons, respectively. the nyc metropolitan region holds the majority of critical care capacity in nys. our data are generally consistent with prior studies of icu resource use due to elective surgery. two 2018 studies of icu use after noncardiac surgery found that elective surgery cases only consumed 13.4% of icu resources and 6.4% of ventilator requirements. 6, 7 figure. this assessment of a relatively minor impact is compounded by the relatively small share of patients after elective surgery that require prolonged ventilationthus suggesting a shorter icu length of stay-when compared to patients admitted to the icu for emergent/urgent/trauma surgery or medical etiologies. a 2000 study of 2 surgical icus also observed that stays after elective surgery rarely were for extended periods while icu stays after emergency surgery were more likely to be prolonged. 8 our data suggesting requirement of mechanical ventilation in 26.3% of icu admissions is likewise consistent with previously reported rates ranging from 20.7% to 38.9%. 9 results presented in the current study have potential implications for resource management in crises requiring heavy use of scarce icu resources. while suspending elective surgeries clearly increases hospital (non-icu) bed capacity, our analysis suggests a limited impact on icu resource allocation, especially in the context of the much larger share of icu admissions due to emergent/urgent/trauma surgery and medical etiologies. a surge in critical care demand requires an orderly deescalation of less essential services to prevent catastrophic failure of the health care system. 10 unfortunately, unlike elective surgery, urgent/emergent/trauma surgery and medical icu admissions cannot be deescalated. suspending elective surgery is controllable, but may only free up limited critical care resources. in the context of covid-19 care, which often requires prolonged courses of mechanical ventilation, 11 the relatively short duration of icu stays after elective surgery 8 suggests that the impact of reducing elective surgery is likely even smaller. combined, these findings point toward greater use of critical care resources in icu admissions not linked to elective surgeries. 11 of specific interest is critical care utilization among patients in the emergent/urgent/trauma surgery group as they represent a larger share of surgical admissions when compared to elective surgery. although data are lacking, we hypothesize that this category of icu utilization may also be impacted through policies such as stay-at-home orders. intended to contain the spread of covid-19, statewide stay-at-home orders may also decrease automobile accidents due to less traffic. such an effect on traffic accidents 12, 13 has been noted in california after statewide stay-at-home orders. reducing exposure to traffic is likely to lead to reduced trauma-related emergency department visits and subsequent critical care utilization. stay-at-home orders may also affect crime-related trauma activity that consumes icu resources, although existing data suggest mixed effects. 14 effects of public health policies on icu resource availability represent an important knowledge gap in disaster planning policy. our data do not address other potential effects of suspending elective surgery. such a decision may only free up limited icu resources, but may also release non-icu hospital beds for covid-19 patients who do not need critical care. reallocating such patients may then preserve existing icu beds. health care workers previously involved in elective surgery may also be redirected to provide care to pandemic patients. reports of redirecting surgeons to perform invasive procedures, operation room (or) teams to position patients in prone position, and nurse anesthetists to manage ventilated icu patients suggest that health care system resource allocation is extremely complex. 15 our study has limitations. first, data from 2011 to 2015 may not accurately represent current icu practice and capacity in new york. however, yearon-year data suggests that the icu capacity in nys and nyc has remained relatively constant during the study period. second, we do not estimate the effects of suspending elective surgery on non-icu beds. changes in these non-icu resources may have secondary effects on icu use. third, the balance of icu resource utilization due to different emergent or elective surgery or medical reasons may be seasonal, suggesting that the effect of elective surgery on icu admissions may vary by time of year. 16 for example, better weather may increase the number of emergent/ urgent admissions/trauma surgery admissions which would further reduce the relative impact of suspension of elective surgeries in terms of icu capacity. in conclusion, we found that, over a 5-year period from 2011 to 2015, icu admissions from patients after elective surgery in new york is likely to have only a small effect on icu bed availability. rather, icu admissions from urgent/emergent surgery and medical sources comprise the majority of icu admissions both in nys and nyc. our results may be valuable for hospital administrators and disaster planning policymakers to optimize the response to future diseases that require heavy use of critical care. e utilization of intensive care services healthcare cost and utilization project (hcup). surgery flags software for icd-9-cm available at: https:// health.data.ny.gov/health/health-facility-certification-information/2g9y-7kqm the society of critical care medicine (sccm) incidence, clinical outcomes, and transmission dynamics of severe coronavirus disease 2019 in california and washington: prospective cohort study intensive care utilization following major noncardiac surgical procedures in ontario, canada: a population-based study european surgical outcomes study (eusos) in spain. intensive care admission and hospital mortality in the elderly after non-cardiac surgery analyzing the impact of long-term patients on icu bed utilization icu occupancy and mechanical ventilator use in the united states surge capacity principles: care of the critically ill and injured during pandemics and disasters: chest consensus statement respiratory pathophysiology of mechanically ventilated patients with covid-19: a cohort study available at: https://data.lacity.org/ a-safe-city/traffic-collision-data-from-2010-to-present/ d5tf-ez2w special report: impact of covid19 on california traffic accidents initial evidence on the relationship between the coronavirus pandemic and crime in the united states innovative icu physician care models: covid-19 pandemic at newyork-presbyterian. nejm catalyst correlating weather and trauma admissions at a level i trauma center key: cord-282026-839jc5wp authors: tsui, ban c. h.; deng, aaron; pan, stephanie title: coronavirus disease 2019: epidemiological factors during aerosol-generating medical procedures date: 2020-06-16 journal: anesth analg doi: 10.1213/ane.0000000000005063 sha: doc_id: 282026 cord_uid: 839jc5wp nan w e read with great interest the important editorial by orser 1 that outlines recommendations for performing aerosol-generating medical procedures (agmps). the coronavirus disease 2019 (covid-19) pandemic places health care workers (hcws) at high risk of exposure. as of april 2020, hcws comprised 10% of the covid-19 cases in italy. 2 we agree that extreme caution must be exercised and preventative strategies be used when performing agmps, including tracheal intubation and manual ventilation, to minimize the risk of transmission. 1, 3 this article broadens the current covid-19 infectious control strategies through the concept of the epidemiological triad to further protect hcws performing agmps. snow, 4 a pioneer anesthesiologist and father of modern epidemiology, first described the epidemiologic triad to trace the source of cholera outbreaks in london in the 1850s. the epidemiological triad ( figure) helps us understand the spread of diseases through 3 components: agent, environment, and host. 4 in the context of covid-19, the agent is the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), including the pathogenicity and virulence of various strains. the environment refers to extrinsic factors that affect the agent and opportunities for exposure like respiratory droplets and contaminated surfaces. the host is any uninfected person and their individual susceptibility characteristics (eg, age, sex, and comorbidities). minimizing the interactions between these components would reduce the spread of covid-19. factors that disrupt the proliferation of covid-19 can be conceptualized into 3 scenarios (figure) : community, hospital, and agmps. "interrupting factors" (ifs) between any 2 components can be categorized as agent-host ifs (decreasing the host's susceptibility or diminishing the virus' virulence), agent-environment ifs (eliminating or decreasing the viral burden in droplets and surfaces), and environment-host ifs (decreasing the opportunity for active virus to infect new hosts). while a covid-19 vaccine and/or treatment is the most effective agent-host ifs, they are still being developed. thus, the focus should remain on promoting practical strategies that optimize environment-host and agent-environment ifs until a vaccine or treatment becomes available. environment-host ifs in the community include shelter-in-place policies and social distancing. similarly, hospitals have implemented interim cancellations of elective surgical cases, restricted hospital visitors, and encouraged personal protective equipment (ppe) use. in both settings, frequent hand washing or disinfection, avoidance of physical contact, and restraint from touching one's face have been vital to controlling the spread of covid-19. 3 during agmps, ppe (including n95 respirators, powered air purifying respirators [paprs], face shields, gowns, and gloves) remains the major environment-host if protecting hcws. for agmps, such as intubation, video laryngoscopy provides slightly more distance between the infected patient and the hcw when compared to direct laryngoscopy, but the hcw still remains at high exposure risk. although various innovative plastic barrier enclosure devices for performing agmps have been widely publicized, 3 these barriers remain an exposure risk when removed or cleaned as the virus is temporarily contained rather than eliminated. following the agmp, hcws must also remain cautious of exposed areas within the barrier, including the patient's head, or table, and the hcw's own clothing, as infectious particles may settle on these surfaces. agent-environment ifs in the community include the self-quarantine of infected individuals, respiratory hygiene, and mask wearing by infected individuals, and restriction of travel from areas with widespread ongoing transmission. in hospitals, airborne infection isolation rooms (aiirs or negative pressure rooms) and dedicated hospital wards with devoted covid health care teams limit transmission to the rest of the hospital. despite these isolation measures, extensive contamination of environmental surfaces is found in the rooms of covid-19 patients. 3 because sars-cov-2 can persist on inanimate surfaces for up to 9 days, surface decontamination with disinfectants is an essential agent-environment if. 3 portable ultraviolet (uv)light disinfection systems utilizing the germicidal properties of uvc (100-280 nm) irradiation have the added benefits of "no touch," maintenance of a room's ventilation, and lack of residue. 3 given the nature of agmps, implementation of agent-environment ifs is challenging. the infected www.anesthesia-analgesia.org letters to the editor patient cannot be isolated from the hcw nor can the patient's body be chemical disinfected or irradiated. high-efficiency particulate air (hepa) filters on ventilator circuits have been used but are only useful in continuity with the patient's airway. a facemask on the patient can decrease the aerosolization of sars-cov-2 into the environment but hinders performance of the agmp. performing an agmp in an aiir or negative pressure or protects only hcws outside of the room. although aiirs require a minimum of 12 air-flow changes per hour (ach) and ors require a minimum of 15 ach, 3 the viral particles are recirculated rather than refreshed resulting in increased exposure risks to the hcws within the room. in fact, the anesthesia patient safety foundation (apsf) and the american society of anesthesiologists (asa) recommend decontamination of the or after care of covid patients and "entry should be delayed until sufficient time has elapsed for enough air changes to remove aerosolized infectious particles." 3 safety practices used by other occupations exposed to hazardous particulates provide a great resource for alternative agent-environment ifs for hcws performing agmps. local exhaust ventilation hoods near the contamination source provide effective control of dust and fumes generated in industries utilizing woodworking and soldering. recently, a similar evacuation system for agmps was described. 5 a commercially available, disposable oxygen face tent was repurposed and connected to a high-efficiency waste management system with a hepa filter to form an aerosol evacuation system. although clinical studies have not been performed, this evacuation system for agmps is encouraging because it is grounded in the same technology used by other high-risk occupations exposed to hazardous particulate matter. as the world begins to relax its protective interventions, we must "beware of the second wave of covid-19." 6 the epidemiological triad provides a framework to decrease the spread of covid-19 by strengthening currently used ifs and refocusing innovative recommendations for endotracheal intubation of covid-19 patients covid-19: protecting healthcare workers is a priority anesthesia patient safety foundation. covid-19 and anesthesia faq. available at re-purposing a face tent as a disposable aerosol evacuation system to reduce contamination in covid-19 patients: a simulated demonstration beware of the second wave of covid-19 key: cord-253281-95ubt4k1 authors: wilson, lauren a.; zhong, haoyan; liu, jiabin; poeran, jashvant; memtsoudis, stavros g. title: return to normal: prioritizing elective surgeries with low resource utilization date: 2020-05-04 journal: anesth analg doi: 10.1213/ane.0000000000004930 sha: doc_id: 253281 cord_uid: 95ubt4k1 supplemental digital content is available in the text. to the editor s uspension of elective surgeries was among the first mitigation efforts in anticipation of a surge in demand for critical care services during the coronavirus disease 2019 (covid-19) pandemic. 1 as the united states nears the peak of this pandemic, policymakers need to determine the optimal strategy to safely return to "normal" operations while remaining vigilant and prepared for future recurrent outbreaks. we therefore evaluated intensive care unit (icu) utilization and mechanical ventilation following common elective surgical procedures to (1) determine which procedures are the least resource intensive and (2) which patient populations are less likely to require postoperative icu admission or ventilation. after institutional review board approval (irb no. 2016-436), we conducted a retrospective analysis of patients captured in the premier healthcare database (2006-2016) who underwent common elective inpatient procedures (supplemental digital content, appendix, http://links.lww.com/aa/d93). 2 for each surgical cohort, we identified icu admission, length of icu (and hospital) stay, and use and length of (non-) invasive ventilation (≥96 or <96 hours). multivariable logistic regression models measured the association between patient age/comorbidity burden as measured by charlson-deyo index, 3 and the outcomes of icu admission and ventilation, to validate the perception that younger and healthier patients are less likely to require these resources. of the 15 elective surgeries evaluated, cardiac procedures were the most resource intensive with 83.9% of patients admitted to the icu and 27.9% requiring ventilation, followed by abdominal procedures that had an average icu admission rate of 20.3%. gynecological surgeries and joint arthroplasties appeared to be the least resource intensive with fewer than 5.5% of patients admitted to the icu and <2% requiring postoperative ventilation (table) . in regression models, greater comorbidity burden was associated with significantly increased odds of icu admission or any form of ventilation in almost all procedure cohorts; this association was more subdued and sometimes reversed for older age (figure) . the highest icu utilization was seen in cardiac, abdominal, and spine surgeries. outside of cardiac procedures, postoperative ventilation was relatively uncommon, indicating that limiting elective procedures is primarily beneficial in maximizing icu capacity rather than freeing up ventilators. in almost all procedure cohorts, younger patients with a low comorbidity burden were less likely to require icu admission and/or ventilation. comorbidity burden was a stronger risk factor and thus should be prioritized over age for optimal patient selection. there is a 2-fold impact of restricting these surgeries to younger patients with a low comorbidity burden. these patients are not only less likely to require icu or ventilation, but they are also at lower risk of developing severe covid-19 symptoms were they to contact the virus during their hospital stay. 4 however, if patients do not meet these criteria and their health could worsen from delaying surgery, it may be advisable to instead space out surgeries of older patients with underlying conditions to optimize resource utilization. limitations of this study include our simplified analysis that only considered patient age and comorbidity burden. while there are a number of other factors associated with icu admission and ventilation, our findings should provide a useful starting point in strategizing to return to normal operations. additionally, some procedures classified as elective in this database may not truly be elective; however, given that they will still be performed during the covid-19 pandemic, we felt valuable information could still be gained from retaining them in our analyses. these data suggest that, in the transition back to elective surgery, cardiac and abdominal procedures should be limited if possible in favor of "safer" and less resource-intensive surgeries such as gynecological and nontraumatic orthopedic procedures. across all procedure cohorts, it would be ideal to restrict or at least prioritize younger patients with fewer comorbidities. maximizing the calm before the storm: tiered surgical response plan for novel coronavirus (covid-19) overview of operating room procedures during inpatient stays in us hospitals adapting a clinical comorbidity index for use with icd-9-cm administrative databases clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study plot of adjusted odds ratios and 95% confidence intervals for the association between patient age/deyo comorbidity index and the 2 outcomes of postoperative icu admission and any ventilation, stratified by surgical cohort 6 (4-8) key: cord-289806-6ihptx6n authors: martinez, rebecca; bernstein, kyra; ring, laurence; ona, samsiya; baptiste, caitlin; syeda, sbaa; aziz, aleha; robinson, kenya; valderrama, natali; sheen, jean-ju; d’alton, mary; goffman, dena; gyamfi-bannerman, cynthia; moroz, leslie; landau, ruth title: critical obstetric patients during the coronavirus disease 2019 pandemic: operationalizing an obstetric intensive care unit date: 2020-10-07 journal: anesth analg doi: 10.1213/ane.0000000000005253 sha: doc_id: 289806 cord_uid: 6ihptx6n supplemental digital content is available in the text. this archetype includes a large number of juniorlevel providers, each of whom are supervised by tiers of more senior-level physicians, who are in turn overseen by a board-certified critical care attending who guides the care of the greatest number of patients. the newly established operating room intensive care unit (oricu) accepted its first sars-cov-2 case on march 23, 2020, with a peak occupancy of 78 patients. the pandemic brought near-complete cessation of nonurgent hospital activities with the rapid expansion of critical care services, with the notable exception of the labor and delivery unit (ldu), which continued to have a full complement of patients presenting for obstetric care. the incidence of sars-cov-2 infection among pregnant women admitted to ldus in nyc hospitals was 15.4%, with 4.7% of them critically ill. 7 there were scarce data about the clinical trajectory of pregnant women with sars-cov-2 infection, specifically regarding the proportion of women requiring mechanical ventilation in the setting of critical hypoxemia. in addition to sars-cov-2 maternal morbidity, usual indications for maternal critical care such as hemorrhagic shock, preeclampsia, cardiac disease, sepsis, and rare fetal indications continue to drive a steady demand for obstetric critical care services, 8 for which obstetric patients are usually transferred to a surgical or medical icu. 9 it became obvious by mid-march 2020 that our institution's icu capacity would rapidly be surpassed and that transferring critically ill obstetric patients per the usual model of care would become challenging, if not impossible. for this primary reason, we made the decision to provide intensive care to obstetric patients on the ldu. by the time the obstetric icu (obicu) was fully operational (end of march), the volume demand was mildly curtailed by some patients electing to leave nyc; however, interinstitutional transfers for maternal or fetal indications provided steady demands for care, with fluctuations occurring week by week. in this article, we describe the steps undertaken in response to the pandemic to create a continuously fully staffed obicu on our ldu, replicating some elements that were implemented in the oricu, in anticipation of the inevitable medical and surgical intensive bed surge at our institution. the guiding ethos was to provide high-quality care in the obicu for critically ill peripartum women (defined as beyond 20 weeks of gestational age through 1 month postpartum) requiring icu care during this pandemic, equal to the quality of care they would have received in the surgical or medical icu. to achieve this primary goal, we followed crisis model management strategies to secure appropriate staffing, space, and supplies. 10 secondary goals included (1) increasing critical care knowledge and competency among providers of all levels who do not care for critically ill patients regularly; (2) ensuring providers' safety by implementing standards for personal protection, and (3) maintaining optimal communication, adaptability, and collegiality in a constantly evolving environment. the obicu structure is based off the innovative pyramidal staffing model that was implemented for the patients in the novel oricu. 6 the oricu was staffed by redeployed nursing, anesthesia, and surgical staff, with 1 critical care attending overseeing multiple cores, but multiple reasons justified adapting this established model (figure) . 6 first, our ldu is located in the new york presbyterian-morgan stanley children's hospital, remote from all icus (medical, surgical, and oricu); accounting for the significant distance between our ldu and all adult icu locations was key. second, we expected the obicu to be at a significantly smaller scale than the 78-bed oricu. instead of transforming operating rooms (ors), we planned to retrofit the existing 6-bed capacity high-risk rooms located on the ldu into the obicu. common indications for admission to high risk would be preeclampsia, cardiac conditions, preterm labor, and peripartum hemorrhage. these 3 high-risk rooms are equipped with maternal and fetal monitoring capabilities and telemetry to accommodate patients who require invasive and intensive monitoring. however, they were not previously equipped with ventilators or equipment traditionally used in an icu. third, and most importantly, we recognized that to provide optimal maternal and fetal care throughout the pregnancy continuum, including the antepartum and postpartum periods, critically ill patients would require different care models. prolonged maternal hypoxemia associated with severe sars-cov-2 infection may result in fetal hypoxemia and ultimately acidemia. thus, an antepartum obicu patient requires multidisciplinary decision-making regarding fetal monitoring and optimal timing of delivery for both mother and fetus depending on the gestational age. while uterine decompression (ie, delivery) may improve maternal respiratory status particularly in the third trimester, potential benefits need to be balanced against the known operative risks if delivering by cesarean, gestational age of the fetus, and desires of the patient or health care proxy. shared decision-making for postpartum patients remains important, but lack of fetal concerns in postpartum patients simplifies the physiologic considerations. bearing in mind these unique considerations, a shared obstetric/anesthesia responsibility model was deployed, adopted from the staffing structure of the oricu. however, a key difference is that the critical care attendings (icu oversight) are not ultimately responsible for patient care decisions and provide ad hoc consultations if deemed needed by the obstetric anesthesia attending. as of march 21, 2020, 1 designated obstetric house staff (senior resident or fellow) is the "first call" team member, reporting directly to the obicu attending, the dedicated obstetric anesthesia attending who is the attending of record ( figure) . this new role for the obstetric anesthesia team was designed with this unique intent to manage critically ill peripartum patients. physicians dual-certified in obstetrics and critical care may also consider covering as an obicu attending; 1 attending from our institution qualified. the obicu attending is in close communication with the maternal-fetal medicine (mfm) attending, as well as ad hoc with a designated critical care attending if specific questions arise. this new role for an obicu attending necessitated reconfiguration of the staffing model to allow for a second in-house obstetric anesthesiologist 24 hours a day. this occurred on march 21, 2020, after 2 postpartum patients with an initially unknown sars-cov-2 infection required a short admission to the adult icu (both were intubated). 11, 12 one attending remained dedicated to supervising labor epidurals and operative cases while the other oversaw the care of the obicu patients. collaboration between the 2 attendings remained critical during surges in clinical demands. creation of the obicu did not require expansion of the anesthesia resident or obstetric anesthesia fellow coverage beyond the continuous coverage by 2 trainees. staffing remained consistent for days, nights, weekends, and holidays. the nursing staffing model of the obicu continued with 1:1 or 1:2 nursing to patient ratio, with 3-4 nurses working every shift, caring for a maximum of 6 obicu patients. this remained similar to coverage of patients before the implementation of the obicu. ldu nurses with critical care obstetric (ccob) training are assigned to care for patients in the obicu. the ccob nurse has at least 2 years of experience and has received both formal training (2 weeks classroom and 2 weeks bedside dedicated icu learning time) and informal teaching from senior-level nurses in caring for patients with critical illness. nursing leadership from the postanesthesia care unit (pacu) and pediatric icu also committed to further education and support of the ccob nurses. the addition of vital ancillary health services was also necessary. leadership from the departments of anesthesia technicians, central venous access, extracorporeal membrane oxygenation (ecmo), facilities maintenance, icu triage (adult and pediatric), nursing, nutrition, occupational and physical therapy, pharmacy, phlebotomy, respiratory therapy and social work committed to providing 24/7 coverage for obicu patients should needs arise. a comprehensive list of contact information prominently displayed preferred communication methods (table 1) . team rounds are conducted twice daily with inclusion of the obstetric anesthesiologists, mfm obstetricians, and obicu nurses. consultants such as pharmacists and respiratory therapists participate, as well. this large team meets in the nursing station with each member wearing mask continuously (in accordance with hospital policy) and socially distancing as much as possible. the "first call" conducts the morning preevaluation of each patient, gathering relevant data and performing a physical examination, and presents each case at the nursing station for a review of patients' vitals and fetal heart tracing, if relevant. an organ systems-based plan is developed by the team and approved by the obicu attending. the plan is communicated to the patient by the obicu and mfm attendings who examine the patient after rounds to minimize staff exposure. between patients, all providers conform to institutional protocols of infection prevention and control. ancillary services are contacted as needed and present on rounds if available. we created the obicu in the existing high-risk unit, which is immediately adjacent to the obstetric ors, www.anesthesia-analgesia.org operationalization of an obstetric intensive care unit during sars-cov-2 pandemic knowing that its function would require adaptation of the existing infrastructure (supplemental digital content, figure 1a , b, http://links.lww. com/aa/d221). an early step was to ensure that all appropriate invasive and noninvasive monitoring devices, including those for maternal hemodynamic and fetal heart rate tracings evaluation, were functional for patient care. a trial run proved that the rooms were large enough to accommodate the needs of 2 patients, including maternal and fetal monitoring systems (philips intellivue mp70 monitor, avante health solutions; philips avalon fm50, philips usa), invasive ventilators (nellcor puritan bennett 840 ventilator system), and multiple infusion pumps (baxter sigma spectrum). centralized monitoring screens in the nursing station allow for the nurses to oversee patients' status while not in the room. as ventilator settings and alarms are neither visible nor audible with the existing monitoring system, standard baby audio monitors were purchased for continual observation of the ventilators. multiple spatial adaptations were necessary to improve safety for patient and staff members. a high priority was the conversion of the 3 rooms to negative pressure airflow to minimize the aerosolization of viral particles into the hallway when the room door was opened. with a conversion from positive to negative pressure, the rooms then met infection prevention and control criteria for airborne isolation and provided safer intubating conditions. further, negative pressure rooms expanded our ability to safely provide more invasive ventilation modes such as continuous positive airway pressure and high-flow nasal cannula. hospital engineers installed a vacuum in each room then cut a large hole in a window for the venting of the room air outward. this created a negative pressure space, so any aerosolized material would be directed outside. another priority included the creation of spaces for donning and doffing. donning stations with necessary equipment in a locked cart were placed outside each room. personal protective equipment (ppe) included hats, masks with shields, gloves, and gowns. doffing stations were located inside each room with relocation of the trash can next to the door and placement of an alcohol-based hand sanitizer dispenser near the door for immediate use. while reconfigured to provide longitudinal care for critically ill women, the high-risk beds converted to obicu beds maintained their capability for women to labor and deliver vaginally. obicu patients requiring cesarean delivery continued to be transferred to the obstetric ors as per usual before the pandemic. two patient-safety-related principles guided our supply chain strategy: preservation and reliable access of supplies. contamination of equipment and supplies (including medications) placed in the room of a patient with sars-cov-2 infection meant that preserving and streamlining supplies were important considerations. the team collaborated to the design of 3 new carts deployed outside each room (supplemental digital content, figure 1b , c, table 1 , http://links.lww.com/ aa/d221): (1) isolation cart, (2) basic nursing supply cart, (3) anesthesia cart, in addition to the institutional code cart. rapid and safe access to icu drugs while avoiding wasting unused but possibly contaminated vials may be a significant challenge at a time when national drug shortages are an issue. structural difficulties prevented the relocation of a drug-dispensing machine into the direct proximity of the obicu. however, the pharmacists adapted the centrally located, existing drug-dispensing machine to include standard medications available in adult icus. this included addition and expansion of sedatives, antiarrhythmic agents, vasopressors, and inotropes. these machines are restocked by the pharmacy teams daily. point of care testing was possible with an epoc blood analysis system (siemens healthineers) at the nursing station of the obicu. anesthesiology residents and obicu attendings trained and certified in its use are available continuously to run samples. these results automatically uploaded to the medical record and immediately available for interpretation by the team. the obicu can admit up to 6 critically ill peripartum patients with the capacity to provide monitoring, invasive ventilation, and management of respiratory failure and vasodilatory shock. the decision regarding patient admission to the obicu is ultimately at the discretion of the obicu attending. a joint taskforce of obstetric anesthesiologists and mfm obstetricians developed guidelines for admission (table 2) . based on these criteria, the covering obicu attending determines if the patient is stable for standard care, needs admission to the obicu, or has critical care needs exceeding the capacity of the obicu requiring transfer to a standard medical or surgical icu. we planned to consider transfer of complex patients including, but not limited to, those requiring cooling after cardiac arrest, continuous renal replacement therapy, ecmo, or mechanical circulatory support. education in the obicu has been an area of rapid development. significant growth and learning on all www.anesthesia-analgesia.org levels of provider (technicians, nursing, house staff, attendings, support staff) has been a recurring theme during all stages of the outbreak and opening of the obicu. systems-based rounding was a new organizational structure for most team members; however, an overview of the benefits of this system as well as modeling by the obicu attending facilitated rapid adoption of this model. interdisciplinary teaching of a wide range of topics from arterial lines to oxygen administration techniques has been important to ensure that patients receive a standard level of intensive care. daily online lectures by the internal medicine or anesthesia departments review critical care topics that are both general in nature and specific to sars-cov-2 infection; these lectures while targeted at residents were available to all members of the obicu team. a virtual toolbox homes a compilation of online resource, articles, and recordings of previous lectures. all staff have access to these resources. new infographics with visual prompts for staff have been designed by the anesthesia residents to improve knowledge and optimize care. there were several challenges that should be perceived as stimulating and constant opportunities for improvement. first, we developed the obicu out of necessity during a pandemic with significant limitations on time, material, and personnel resources. delivering icu-level care in a space that was not designed for critical care imposes spatial inefficiencies. the quality of nursing care for critically ill patients is well correlated with outcomes, 13 and the majority of the nurses working in the ldu were not initially trained in ccob. these paradigms are not unique to nursing; operating outside ones' scope of practice results in the delivery of care that is not as seamless as within teams that consistently work together with critical care patients. occasionally the covering pharmacist and respiratory therapist were not invited to rounds; this required communication outside of the team rounds to minimize care oversights. in another instance, the heparin downtitration in the setting of supratherapeutic activated partial thromboplastin time was delayed because the covering resident was unaware of the titration protocols. inevitable gaps in theoretical and applied knowledge must be filled by the team leaders, who have differing levels of comfort in managing details pertinent to critically ill patients. nonetheless, help from across the institution facilitated the obicu function. pacu and pediatric icu nurses offered to provide assistance as needed. critical care physicians were available constantly for in-person consultations. most importantly, because a joint effort of multiple departments collaborated to design the obicu environment, each person's contributions to patient care on rounds are valued. the success of the system depends on a collaborative, communicative team. despite obvious challenges of designing and implementing an obicu, this is a scalable model for expanding care services. there are many advantages for critically ill pregnant women to receive care in a closed unit where obstetric anesthesiologists and obstetricians/mfm are accustomed to working together. a timely decision to proceed with delivery, via labor induction or cesarean delivery, can optimize maternal and fetal outcomes in critically ill obstetric patients. facile administration of neuraxial anesthesia can be particularly valuable in these patients as a strategy to avoid general anesthesia and its inherent risks (to both patients and providers) during the sars-cov-2 outbreak. while our obicu is led by the obstetric anesthesia team, its success is predicated on multidisciplinary effort with collaboration across departments (anesthesia, obstetrics, nursing, management, and critical care) to provide optimal medical care during a time of crisis. daily virtual meetings with various stakeholders facilitated communication and allowed for www.anesthesia-analgesia.org operationalization of an obstetric intensive care unit during sars-cov-2 pandemic rapid response to logistical difficulties. collegiality and a commitment to team learning are important as the unit evolves. twice daily multidisciplinary rounds with attendings from obstetrics and anesthesia remain a critical element for patient safety and ensure optimal communication. finally, a commitment to flexibility and professionalism in the face of new clinical and operational challenges allowed for peripartum patients to receive high-quality, safe care during a global pandemic. e initial clinical impressions of the critical care of covid-19 patients in seattle covid-19: role of ambulatory surgery facilities in this global pandemic telehealth for high-risk pregnancies in the setting of the covid-19 pandemic asian critical care clinical trials group. intensive care management of coronavirus disease 2019 (covid-19): challenges and recommendations innovative icu physician care models: covid-19 pandemic at newyork-presbyterian. catalyst non-issue content universal screening for sars-cov-2 in women admitted for delivery critical illness in pregnancy: part i: an approach to a pregnant patient in the icu and common obstetric disorders consultation, surveillance, monitoring, and intensive care (cosmic): a novel 4-tier program to identify and monitor high-risk obstetric patients from the clinic to critical care institute of medicine (us) committee on guidance for establishing standards of care for use in disaster situations. guidance for establishing crisis standards of care for use in disaster situations: a letter report operational implementation of crisis standards of care coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals lessons learned from first covid-19 cases in the united states impact of critical care nursing on 30-day mortality of mechanically ventilated older adults key: cord-263087-fhn4m2zc authors: yang, yao-lin; huang, ching-hsuan; luk, hsiang-ning; tsai, phil b. title: adaptation to the plastic barrier sheet to facilitate intubation during the covid-19 pandemic date: 2020-05-04 journal: anesth analg doi: 10.1213/ane.0000000000004923 sha: doc_id: 263087 cord_uid: fhn4m2zc nan to the editor w e read with interest the recent article by brown et al, 1 titled "barrier system for airway management of covid-19 patients" which described the use of a plastic drape attached to a plastic bag as a protective measure during endotracheal intubation and extubation. we wish to commend the authors on developing this technique, which has a great benefit of containing and facilitating the disposal of contaminated surfaces surrounding the patient's airway at the end of the surgical case. because of its close geographical proximity to china, taiwan had been on alert for coronavirus disease 2019 (covid-19) as early as december 31, 2019. 2 as more and more information was learned regarding the virulence of severe acute respiratory syndrome coronavirus 2 (sars-cov-2), we used a plastic drape at our institution to protect anesthesia professionals during airway manipulation but made modifications to our technique as problems arose during proof of concept and real-world use. we found that when intubation of the airway was challenging, manipulating the laryngoscope under a sheet proved to be problematic. although brown et al 1 proposed the removal of the clear drape during midlaryngoscopy as an option should difficulties with intubation arise, elimination of the barrier sheet defeats its purpose of protecting the operating room staff, and may further aerosolize viral particles on and under the drape when it is removed in an emergent manner. to facilitate intubation, we make the following adaptations to the plastic sheet. we cut a small 3 × 3 cm cross in the drape with a surgical blade and reinforce the perimeter of the cross with tape so it does not widen over the course of the case (figure, panel a). the purpose of this first x is to connect the anesthesia breathing circuit to the oxygen facemask under the drape (figure, panel b) . a second 2 × 2 cm cross is cut and reinforced in close proximity to the first ( figure, panel a) . the purpose of this second x is for passage of the videolaryngoscope, endotracheal tube, or yankauer suction tip. at our institution, we use the trachway video light stylet (markstein sichtec medical corp., taichung, taiwan) as the preferred video-assisted intubating device (≈5000 cases in 2019). because of its small profile, only a small x is needed to introduce the intubating device and endotracheal tube (figure, panel c). when using the video stylet, we cover the second cross with a small transparent film dressing, making a small nick in the center of the dressing with a surgical blade. as the stylet and endotracheal tube are introduced, the hole in the film will dilate in size to accommodate the endotracheal tube, while the elasticity of the dressing allows it to adhere around the tube, minimizing the defect in the plastic barrier. if a videolaryngoscope is utilized for intubation, the cross is widened to 3 × 3 cm to accommodate passage of both the disposable blade and the endotracheal tube. a transparent dressing should not be utilized with videolaryngoscopy as the film's adhesive nature may interfere with the maneuvering of laryngoscope or endotracheal tube, but a dressing can be placed adaptation to the plastic barrier sheet to facilitate intubation during the covid-19 pandemic figure. adaptation to plastic sheet to facilitate endotracheal intubation. a, two diagonal crosses are cut into the drape and reinforced with tape. b, first cross allows connection of breathing circuit to oxygen facemask. c, second cross allows introduction of video stylet and endotracheal tube. www.anesthesia-analgesia.org letters to the editor over the x after successful intubation to reduce the size of the defect in the plastic sheet. typical airway maneuvers, such as jaw thrust by an assistant, can still be performed over the sheet. if mask ventilation is needed after an initial laryngoscopy attempt, we can easily shift the plastic drape back over to the first cross to allow resumption of mask ventilation. a benefit of utilizing a plastic sheet as the barrier device is that it is simple and inexpensive and can be constructed with existing materials in the hospital, such as a surgical drape or even a plastic trash bag. the use of a transparent acrylic intubation shield has been proposed and may afford improved visibility but would require construction of the device as well as disinfection of the unit after each use. 3 in addition, patient anatomy may preclude effective manipulation of the airway through the 2 circular openings. a potential negative aspect of our modified drape technique is the theoretical transmission of viral particles into the operating room through the defect in the barrier. however, we feel that the risk of contamination is low, and our modified technique improves the success rate of the initial intubation attempt, especially when a difficult airway is encountered. if additional protection is desired, using 2 plastic drapes as a double layer can further reduce the risk of accidental transmission, as the xs on both sheets would have to be aligned in order for aerosolization of viral particles to occur. although we have been carefully removing the drape after successful intubation, we feel that brown et al 1 and other authors make an excellent point that the sheet can be left in place for the duration of surgery, and the patient can be subsequently extubated under the drape, shielding anesthesia providers and other operating room personnel when the endotracheal tube is removed. 4 during these trying times, it is encouraging to see how health care professionals over the globe are readily sharing clinical insights, and we hope that our experiences with a simple modification to the barrier sheet method may help others improve their success rate of initial intubation while still providing protection to anesthesia professionals during the covid-19 pandemic. barrier system for airway management of covid-19 patients response to covid-19 in taiwan: big data analytics, new technology, and proactive testing barrier enclosure during endotracheal intubation clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for covid-19 key: cord-322784-eqfjrceq authors: li, yunping; ciampa, erin j.; zucco, liana; levy, nadav; colella, meredith; golen, toni; shainker, scott a.; lunderberg, j. mark; ramachandran, satya krishna; hess, philip e. title: adaptation of an obstetric anesthesia service for the severe acute respiratory syndrome coronavirus-2 pandemic: description of checklists, workflows, and development tools date: 2020-10-15 journal: anesth analg doi: 10.1213/ane.0000000000005256 sha: doc_id: 322784 cord_uid: eqfjrceq care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (sars-cov-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. the exponential community spread of disease limited the time for development and training. methods: the goals of our workflow and process development were to maximize safety for staff and patients, minimize therisk of contamination, and reduce the waste of unused supplies and materials. we used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. results: we designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. in addition, we created procedure-specific material packs to optimize supplies and prevent wastage. finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. conclusions: collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. over time, we refined the workflows using a cyclical improvement system. we present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit. s imilar to previous coronavirus epidemics, the novel severe acute respiratory syndrome coronavirus-2 (sars-cov-2) virus is spread primarily by droplets or contact from symptomatic individuals; however, sars-cov-2 appears to also be transmissible from individuals who have not yet displayed symptoms. 1 the virus replicates to high titers in the upper airway with high degrees of shedding during the first week of symptoms. 2 additionally, aerosolization of the virus can occur with certain procedures, such as endotracheal intubation or extubation. the high rate of transmission poses significant risks to all health care workers, other patients, and bystanders without appropriate preparation. 3, 4 the first case of coronavirus disease 2019 (covid-19), the disease caused by the sars-cov-2 virus, was identified in massachusetts on february 1, 2020. but it was not apparent how the virus would affect the commonwealth until a month later when a cluster of 70 cases was identified among attendees of a scientific conference in boston. this was approximately the same time that the world health organization declared a global pandemic on march 11, 2020. 5 in preparation for the pandemic, we reviewed relevant literature and recommendations specific to anesthetic care, which appropriately focused on operating room preparation 6 and patient management during airway manipulation and transport, 4, 7, 8 with a notable paucity of literature detailing preparation tailored to obstetric anesthesia. 4, 9 the delivery of anesthesia on the labor and delivery (l&d) unit is distinct from the care in the intensive care unit (icu) or in the operating room. in many cases, the method of delivery is unknown until the end and may emergently change with little notice. clinicians must also prepare for unexpected operative and nonoperative procedures such as management of postpartum hemorrhage or emergent cesarean delivery. thus, the impact of sars-cov-2 in obstetric anesthesia required the creation of parallel workflows to simultaneously deliver high-level care to pregnant patients with and without covid-19 for labor analgesia, cesarean anesthesia, and other procedures. while we appreciated that the rapid spread of this virus would expedite the time to the presentation of the first patient in our l&d unit, the first patient with covid-19 was admitted to our unit overnight for observation before planned preparedness steps had been completed. this unexpected admission resulted in a significant waste of material supplies, because our infection control consultants recommended all disposable supplies in the patient's room to be discarded following their stay. this report describes the processes we subsequently used to rapidly adapt our obstetric anesthesia service and the solutions to reduce waste, maintain safety, and support effective care of patients with confirmed or suspected sars-cov-2 infection. because the sars-cov-2 virus will not likely disappear until effective vaccines are developed, the disease will continue to spread to locations that are not currently heavily affected and maybe ill-prepared to care for the patient while keeping health care workers safe. our goal is to provide materials that may assist others in improving their units and discuss a system that can be used for rapid preparation during a future crisis. 10 this article reports all appropriate components of the revised standards for quality improvement reporting excellence (squire 2.0), published on september 15, 2015. this was classified as a quality improvement study and was determined to be exempt from institutional review board review and did not require informed consent. the study was performed in a tertiary care facility and teaching hospital for harvard medical school serving an urban area with a metropolitan population of 4.6 million. the medical center is the regional referral center for the beth israel lahey health network which delivers 15,000 pregnant patients, annually. our intent was to develop a system of care that would satisfy several aims: • provide full and simultaneous services for both infected and noninfected patients • rapidly adapt to new workflows • maximize safety for staff and patients through standard practices • minimize risk of contamination during procedures • optimize supplies and materials the development of these critical adaptations was performed using cyclical improvement methodology in combination with plus-delta debriefing. these tools were used to create workflows consisting of sequential checklists and procedure-specific packs. workflows were distributed via e-mail to all clinicians, recorded on video and made widely available, posted as laminated pages in appropriate locations, and published on the hospital intranets. each of these was updated with each change in a workflow. we used a cyclical improvement methodology to design each new workflow. cyclical improvement is based on the plan-do-study-act methodology introduced by w. edwards deming for learning and improvement. 11 the initial step was the creation of a process map detailing each step of the workflow, including donning and doffing personal protective equipment (ppe), detailing every step a clinician may take during a procedure. we also defined possible deviations of expected outcomes, for example, when additional materials may be needed, or a change in anesthetic plan. after the creation of the initial process map, we performed small-group in situ simulations using a clinician, an observer, and an event recorder. the clinician simulated performing each step read to them by the recorder, including the use of equipment and medications. the observer's role was to (a) confirm that all steps were completed, and (b) identify where breaches in protocol could result in substandard outcomes. based on simulation findings, the workflow was revised, and the cycle was repeated. after achieving a workflow that was stable, the process was presented to clinicians for use in patient care. after each case, a debriefing was conducted, and the workflow was updated based on these findings. based on previous experience at our center, we modified the plus/delta format for debriefings of our processes and workflows after each real-time test. this method is commonly used and well described in aviation training. 12 our experience is that this exercise lends itself well for rapid cycle improvement. the debriefing team leader begins the session by directing focus on the events and processes (the system) as opposed to any individual actions. participants are notified that commentary or concerns with individual clinical performance will be addressed separately. participants are prompted to discuss what went well in the system (plus); this strategy is intended to ensure that the strengths of the system are identified and are not changed in future iterations. the debriefing leader then focuses the discussion on processes that could be improved or changed (delta). this may resemble a short, focused brainstorming session where clinicians recommend alternate workflows or ideas for improvement. the debriefing ends with a request that additional ideas for improvement be brought forward at any time. debriefings following neuraxial labor analgesia procedures with covid-19 patients were performed with the director of obstetric anesthesia and frontline clinicians. debriefings after each operative procedure on covid-19 patients involved frontline clinicians, plus leadership personnel from the divisions of obstetric anesthesia and quality and safety, l&d nursing, the department of obstetrics and gynecology, and the department of neonatology. the labor analgesia workflow consisting of the checklist, procedure-specific packs, and guidance graphics underwent 2 cycles of small-group simulation. before any opportunity for further refinement, the workflow was then urgently required to be used for clinical care. after each use, the workflow underwent redesign using the cyclical improvement process. within a week, opportunities for refinement were no longer being identified during debriefings. the sequential checklist is presented in figure 1 . preparation for operative procedures represented greater complexity due to the range of distinct modes of anesthesia that can be required, the number of collaborative services involved, and the need to redesign the procedural space for covid-19 patients. our l&d operating room preparation process drew from the perioperative covid-19 pathways under development for the general operating rooms at our institution by the division of quality, safety, and innovation of the anesthesia department, and in consultation with infection control. preparation for operative procedures in patients with covid-19 included dividing isolation space for infected patients into distinct work zones (clean area, transition anteroom, and contaminated procedure room) that minimized the risk of contamination. the unit was separated such that 1 operating room and 4 labor rooms were sealed from approach to the rest of the unit, with the hallway representing a transition anteroom (supplemental digital content, figure 1 , http://links.lww.com/aa/d222). each labor room was stocked with the minimal necessary equipment while operating room preparation was based on reports from previous epidemics. we removed all nonessential materials and supplies from the operating room and wrapped remaining surfaces in plastic covering (supplemental digital content, figure 2a , http://links.lww.com/aa/d222). the perioperative case workflow was distributed to a multidisciplinary group including representatives from obstetrics, maternal-fetal medicine, obstetric anesthesia, neonatology, and the anesthesia division of quality and safety. the group was able to perform 1 cycle of cognitive review. unfortunately, before attempting in situ simulations to refine the workflow or disseminate and train frontline staff, the process was urgently needed for clinical care. each use of the workflow was followed by the cyclical improvement process, including thorough team debriefing and redesign, until achieving a final form, which took approximately 11 cycles (figure 2 ). we initially expected the team leader to be a physician but found that the anteroom nurse had the greatest situational awareness and was best suited to this task. while the identification of the clinicians who enter the operating room with a patient was clear, defining the order of caregivers leaving the room was challenging. especially with the emergence of general anesthesia, we wanted to minimize the number of individuals in the operating room while still having resources to deal with emergencies. additional supplies are frequently needed during procedures; thus, we designated a "runner" for both nursing and anesthesia who waited in the anteroom and would be contacted by the nurse inside the procedure room via hands-free communication headset. because of the expected low frequency of both general anesthesia and postpartum hemorrhage among our patients, we enclosed supplies for these contingencies in a cart housed in the pared-down operating room that would be sealed to prevent contamination but easily accessed when required (supplemental digital content, figure 2b , http://links.lww.com/aa/d222). when there was a need to perform these procedures, the cart would be unsealed; unused supplies would be discarded, and the cart and reusable supplies would be decontaminated. we found this to be far superior to a plastic bag, especially for heavy and bulky supplies. finally, we used an easily decontaminated metal cart as a work surface when a debrief identified that the anesthesiologist had no place to organize supplies (supplemental digital content, figure 2c , http://links.lww.com/ aa/d222). to avoid wasting supplies and to minimize the time required for decontamination, we decided not to use the neuraxial supply cart that we normally bring into the room for procedures. instead, we composed a list of minimum supplies to be stored in procedurespecific packs. plastic bags containing the necessary supplies were assembled and labeled for various clinical scenarios. to accompany each pack, we developed a list of just-in-time items that would need to be obtained immediately before the procedure, such as medications and ancillary supplies that could not be stockpiled. these were printed on a paper and affixed to each pack to minimize the need for clinicians to call out requests for additional materials during a procedure. individualized procedure packs were developed for: • neuraxial for labor (figure 3) • spinal or combined spinal-epidural anesthesia ( figure 4 ) • conversion of labor epidural to cesarean anesthesia • general anesthesia the sars-cov-2 virus and associated covid-19 pandemic place significant pressure on the obstetric anesthesia care provider to simultaneously care for infected and noninfected patients. multiple parallel plans must be made for labor analgesia, cesarean anesthesia, emergent conversion from labor to cesarean, and the management of acute complications such as postpartum hemorrhage. in addition, these plans must be coordinated with the obstetric, nursing, and neonatology services in a way that does not increase risk to patients or clinicians. in translating recommendations from governmental organizations and the major societies into clinical guidelines, we realized that variability in individual interpretation could lead to deviation from best figure 3 . the procedure-specific card for neuraxial procedures for labor analgesia. this card details the contents of the preassembled pack, and also the items that the clinician collects immediately before a procedure, including medications and additional materials. this paper is attached to the pack. bmi indicates body mass index; pf, xxx; tb, xxx. www.anesthesia-analgesia.org anesthesia & analgesia ob anesthesia during practices that carries higher risk of accidental contamination. 13, 14 this is especially critical during donning and doffing ppe. 15 we chose to define standard operating procedures in the form of checklists to ensure the completion of critical steps for clinical care; however, as we simulated performance of a neuraxial labor analgesia procedure, we came to appreciate that it would be easy for clinicians to become contaminated if individual steps were performed out of sequence. we changed from a traditional checklist to one that explicitly defined the temporal sequence of steps. the sequential checklist minimizes deviation from a standard operating procedure and ensures the necessary steps to always provide a "clean" layer of gloves and coverings. additionally, having an observer who ensures that each step is followed is crucial to protecting ourselves and our colleagues. 13 that both the first labor analgesic and the first cesarean were performed by clinicians who were not engaged in the development of our covid-19 workflows suggests that this method can be used to enforce a standard operating procedure in a novice population. clearly, these checklists do not take the place of education and training of a skilled workforce but can be used in an emergency to reduce the risk of error. using a cyclical improvement approach allowed us to rapidly design and iteratively refine our workflows after each live case, and to achieve final products very quickly. we see important advantages to the inclusion of frontline clinicians in the cyclical redesign process: stakeholders gain the expectation that the processes will continue to evolve over time, thus reducing the frustration of a constantly changing protocol, and related gains are tied to the sense of buy-in created among clinicians who feel that their input will play a part in the evolution of workflow. recent difficulties with the medical supply chain nationally were reflected in our hospital and left us acutely aware that the wastage of supplies would impact our ability to care for patients. before this pandemic, the usual method of obtaining materials was to either stockpile supplies in cabinets inside the operating room, or to carry them in a specialized cart. because of the risk of contamination, unused supplies in the patient location need to either be decontaminated or wasted after use by a covid-19 patient. our procedure packs specific for each anticipated type of anesthesia encounter simplified, standardized, and minimized clinical supplies. we are unaware of a case when the wrong pack was chosen for a procedure, but this is likely to happen at some point. our designation of a "runner" to deliver supplies to the procedure room would allow the correction of this error. our workflows and checklists, as well as the redesign of our procedural areas, reflect institutional needs and practices. in a broader view, we believe that the methods we used for adaptation can be used to refine practices at other institutions and in other situations . procedure-specific pack contents for neuraxial anesthesia (spinal or cse) cesarean delivery. the right side of the card identifies the contents of the preassembled procedure bag that a clinician will pick when performing a spinal or cse for cesarean delivery. the left side of the card identifies the medications that are needed to be removed immediately before placement. bp indicates xxx; cse, combined spinalepidural; ekg, xxx; lr, xxx; tb, xxx. that require rapid practice changes. in addition to what we present, the society for obstetric anesthesia and perinatology (soap), 9 obstetric anaesthetists' association (oaa), 16 and anesthesia patient safety foundation 17 have published a number of resources to consider when preparing an obstetric anesthesia service. both obstetric organizations recommend early epidural placement during labor, avoidance of general anesthesia, and training and simulation of critical tasks, such as donning/doffing and patient transport. video laryngoscopy is suggested if general anesthesia is required. soap recommendations include the screening of all patients admitted for scheduled/elective procedures and the use of teleconferencing to minimize contact with patients. the oaa resources include additional checklists, which might be useful for adaptation. in conclusion, we share here our obstetric anesthesia pathways for dissemination, because they may be of assistance to other centers experiencing similar challenges related to the covid-19 pandemic. we also describe the tools that we used to develop these workflows, because they comprise a system that can be generalized to any crisis where a rapid change in processes is needed. e public health-seattle and king county and cdc covid-19 investigation team presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility virological assessment of hospitalized patients with covid-2019 severe acute respiratory syndrome (sars) characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention covid-19) outbreak. the world health organization preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore outbreak of a new coronavirus: what anaesthetists should know anaesthetic management of patients during a covid-19 outbreak. association of anaesthetists interim considerations for obstetric anesthesia care related to covid19. the society for obstetric anesthesia and perinatology history in a crisis -lessons for covid-19 out of the crisis facilitation and debriefing in aviation training and operations. ashgate practical experiences and suggestions for the 'eagle-eyed observer': a novel promising role for controlling nosocomial infection in the covid-19 outbreak common breaches in biosafety during donning and doffing of protective personal equipment used in the care of covid-19 patients chinese society of anesthesiology, chinese association of anesthesiologists. perioperative management of patients infected with the novel coronavirus: recommendation from the joint task force of the chinese society of anesthesiology and the chinese association of anesthesiologists college of anaesthetists-covid-19 guidance. obstetric anaesthetists' association perioperative considerations for the 2019 novel coronavirus (covid-19). anesthesia patient safety foundation key: cord-011656-zln7zmn9 authors: subedi, asish title: medical ethics versus healthcare workers’ rights: fight-or-flee response date: 2020-06-16 journal: anesth analg doi: 10.1213/ane.0000000000005060 sha: doc_id: 11656 cord_uid: zln7zmn9 nan to the editor i read with great interest an article by bong 1 on coronavirus disease 2019 (covid-19) impact on low-and middle-income countries (lmics). this article deals with the several health care problems faced in lmics, and the authors have provided solutions to overcome it. before i share my views, i would like to introduce my current workplace. i am working as an anesthesiologist in a tertiary care hospital situated in the eastern part of nepal. my country is sandwiched between 2 big giants, china and india. while china has flattened the covid-19 curve, india is between stages 2 and 3 of the coronavirus pandemic. as of april 17, 2020, nepal has reported 16 confirmed cases (14 active and 2 recovered), with no casualty. the government of nepal imposed the lockdown timely to combat covid-19 spread and is planning to extend the ongoing lockdown. although social distancing limits the virus spread, it is not the only solution. moreover, with a porous border with india, there is a high chance of importing the virus. perhaps, we are just 1 month behind from where india is in the current situation. this has caused fear, panic, and anxiety among us-the frontline health care providers. it is the same feeling before doing the bungee jump. a recent survey revealed that nearly half of the health care workers treating covid-19 patients experienced symptoms of depression, while about one-third of them suffered from insomnia. 2 this report highlights the importance of psychological well-being of health care workers involved during the covid-19 tsunami. unfortunately, mental health is often neglected in our part of the world. to overcome the mental stress, the government should provide social securities and incentives to health care workers, and moral support to reassure how important we are to the country and the sacrifices we are doing at this crisis. at the individual level, one needs to incorporate relaxation techniques and positive coping behaviors, eat regular and balanced meals, maintain sleep hygiene, and stay connected with closed ones. ultimately, this would help to strengthen our resilience to combat the lifethreatening situation. one of the reasons on how south korea curbed the covid-19 spread was due to its excellent coordination between public and private hospitals. private hospitals contribute a major role in the health care system of any lmics. survey studies from nepal showed that: private sector (hospitals and medical colleges) owns two-third of the hospital beds; roughly half of country's doctors work in a private hospital; majority of patients with acute illness seek care in the private hospital; and out of 480 intensive care unit (icu) beds available in the capital city of nepal, 330 beds belong to the private sector. 3, 4 therefore, the government should collaborate with the private hospital sector to fight against the covid-19. the other issue is related to the availability of personal-protective equipment (ppes). all guidelines recommend ppes compulsory to the anesthesiologist managing covid-19 patients. but access to ppes is far from the reality. for example, according to the covid-19 rapid response team of our hospital, at present, we have only 140 complete set of ppes. these ppes were provided by the government of nepal and donors from nongovernmental organizations. the authors correctly pointed out that in today's crisis, lmics heavily rely on financial assistance from affluent countries and international organizations. 1 while, at this moment, when the rich countries are struggling to get the ppes for their own health care workers, we will only have a handful of these ppes by the time it reaches our place. one solution to this is to encourage the local entrepreneurs, innovators, and private sectors to produce ppes. the government of nepal has already granted the permission to national innovation center to produce ppes. 5 although these protective gear might not be of american or european standards, at least, they provide a sense of safety for us. also, for the decontamination of used ppes on large scale, the lmics should develop innovative techniques, such as hydrogen peroxide vapor sterilization. the reprocessing of ppes followed by its reuse would help us to minimize the shortage. finally, the current scenario reminds me of my country's history on how the "gurkhas" with a curved knife weapon, "khukuri," fought against the wellequipped forces of the british east india company. 6 history has repeated again. by the time my opinion gets published in anesthesia & analgesia, i will be on the battlefield with "khukuri" in my hand fighting against the ak-47 (ie, covid-19 virus). the covid-19 pandemic: effects on low and middle-income countries factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 private gain, public pain: does a booming private healthcare industry in nepal benefit its people? available at intensive care units in the context of covid-19 in nepal: current status and need of the hour amid shortage of ppe, national innovation centre begins its manufacturing in bhaktapur key: cord-257729-s0vo7dlk authors: bauer, melissa; bernstein, kyra; dinges, emily; delgado, carlos; el-sharawi, nadir; sultan, pervez; mhyre, jill m.; landau, ruth title: obstetric anesthesia during the coronavirus disease 2019 pandemic date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004856 sha: doc_id: 257729 cord_uid: s0vo7dlk with increasing numbers of coronavirus disease 2019 (covid19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in the united states, preparation for the unpredictable setting of labor and delivery is paramount. the priorities are 2-fold in the management of obstetric patients with covid-19 infection or persons under investigation (pui): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). the goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the covid19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice. t he management of obstetric patients infected with coronavirus disease 2019 (covid19) due to human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) requires quite unique considerations-from caring for critically ill pregnant and postpartum women to protecting health care workers from exposure during the delivery hospitalization (health care providers, personnel, family members, and beyond). the goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the covid 19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice. in principle, the clinical characteristics reported in pregnant women with confirmed covid-19 infection in china have been consistent with those reported among nonpregnant adults, with better maternal and neonatal outcomes with covid-19 infection compared with the 2002-2003 severe acute respiratory syndrome (sars) outbreak from sars cov 1 infection. [1] [2] [3] the signs and symptoms of covid-19 infection in a large data set in nonpregnant patients from china were fever (99%), fatigue (70%), cough (59%), shortness of breath (31%), myalgias (35%), headache (6.5%), sore throat (17%), diarrhea (10%), nausea (10%), and vomiting (4%). 4 an additional manifestation noted among patients with covid-19 infection is the sudden loss (or reduction) of the sense of smell and taste, which is currently recommended by the american academy of otolaryngology-head with increasing numbers of coronavirus disease 2019 (covid 19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in the united states, preparation for the unpredictable setting of labor and delivery is paramount. the priorities are 2-fold in the management of obstetric patients with covid-19 infection or persons under investigation (pui): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). the goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the covid 19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice. and neck surgery as part of screening for covid-19 infection. 5 in pregnancy, presentation of covid-19 infection appears similar, but many of these nonspecific symptoms may be attributed to symptoms of pregnancy and labor. 2 for example, signs of latent labor may include myalgias and diarrhea; preeclampsia can present with headache; shortness of breath is perceived during pregnancy and labor; and chorioamnionitis may cause tachycardia and fever, thus, leading clinicians to overlook covid-19 infection as a possible diagnosis. in addition, women infected with covid-19 may be asymptomatic until their admission in labor and beyond, 6 which in itself poses a significant risk of exposure for their family members (including the newborn) and all providers involved in their clinical care. screening criteria for covid-19 infection usually include the following: (1) fever, (2) cough or shortness of breath, (3) diarrhea, and (4) any possible exposure to covid-19. however, because women with covid-19 infection may be asymptomatic at the time of admission and because some may present with overlapping pregnancy symptoms, universal screening may miss pregnant women infected with sars-cov-2 in communities with a high prevalence or high projected infection rate (eg, new york, new orleans, detroit, chicago, miami). 7, 8 universal testing with real-time reverse transcriptase-polymerase chain reaction (rt-pcr) tests for sars-cov-2 viral ribonucleic acid (rna) may improve case detection in high prevalence communities. however, current assays may return false-negative results if the viral load is low or if specimen collection is incomplete. the goals of covid-19 testing specific to pregnant patients admitted to labor and delivery units are 2fold: (1) to prevent vertical transmission and ensure separation of the neonate after birth and (2) to protect health care workers by ensuring use of appropriate personal protective equipment (ppe). besides the unclear sensitivity of rt-pcr testing, the time for nucleic acid detection varies between 6 and 8 hours or longer depending on availability. therefore, management of women on labor and delivery units located in a community with a high prevalence of covid-19 infection should err on the side of caution. for purposes of clinical management and ppe use, women may therefore be categorized as follows (1) covid-19 negative, (2) asymptomatic, (3) symptomatic (persons under investigation [pui]), and (4) personally positive for covid-19 testing. this information should be made available to all health care providers and updated at all times as it may change during the course of labor (from asymptomatic to symptomatic or, if tested, once the result becomes available). women who are covid-19 positive (or high-risk pui) should ideally be placed in an isolation room. airborne infection isolation rooms (single-patient negative-pressure rooms with a minimum of 6 air changes per hour), if available, should be used if performance of aerosolizing procedures is anticipated. in general, isolation rooms suitable for droplet and contact precautions are recommended. 9 strategies for exposure mitigation and cohorting, as well as considerations for transportation of patients who are pui or covid-19 should follow the same recommendations as for general patient cases. 10 a multidisciplinary team of anesthesiologists, obstetricians, labor and delivery nurses, neonatologists, critical care experts, infectious disease and infection control experts, employee health services, environmental health services, and telemedicine services should create and implement protocols to support the management of patients with covid-19 infection in the setting of a labor and delivery unit. a sideby-side comparison of recommendations from many professional societies for labor and delivery units is presented in table 1 . for institutions with multiple labor and delivery sites, consideration should be given to designating 1 institution to care for patients with covid-19 infection. this proved useful in managing patients during the sars epidemic and for cases in the recent covid-19 outbreak in wuhan, china. [11] [12] [13] resource allocation within the labor and delivery unit as well as other units (including intensive care unit) should be proactively addressed. it is imperative to establish a back-up team to care for patients without covid-19 infection due to the time-intensive tasks of donning/doffing ppe, transporting the patient, providing anesthetic care, and performing surgery in patients with active covid-19 infection. from a logistical standpoint, a designated operating room within the labor and delivery unit should be prepared. dedicated trays (or carts) containing the most commonly used supplies and drugs for both neuraxial labor analgesia and cesarean delivery should be available to minimize traffic and contamination of anesthesia workstations and other anesthesia equipment. a pregnant woman who is pui or covid-19 positive should be evaluated (limiting unnecessary encounters) including vital signs, physical examination, and review of laboratory tests (complete blood count, comprehensive metabolic panel, and arterial blood gas, if needed) to assess appropriate level of care and monitoring plan for potential deterioration. early multidisciplinary collaboration should be arranged to determine level of care, fetal monitoring, and delivery plan. discussion of the risks and benefits for administering steroids for fetal lung maturity, magnesium for neuroprotection, and indomethacin for tocolysis should be addressed, since there is concern those drugs may worsen covid-19 infection (table 2) . 9 avoiding urgent cesarean delivery is essential to reduce the risk for general anesthesia and provider exposure during uncontrolled transfers to the operating room. therefore, ongoing assessment of both maternal and fetal statuses are key to balance risks of prolonged labor versus cesarean delivery. it is unclear whether uterine decompression improves maternal respiratory status and how the potential benefit balances against the known operative risks in the setting of covid-19. on the other hand, prolonged maternal hypoxemia may ultimately cause fetal acidemia, leading to a more urgent cesarean delivery. 9 routine monitoring should include frequent vital signs (tailored to the current clinical status and adjusted as necessary) with the addition of continuous pulse oximetry and strict input and output measurements to assure fluid restriction. pulse oximetry goal should be an oxygen saturation ≥95%. early warning criteria systems specific for obstetric patients may aid in early detection and prompt escalation of care. 16 women requiring supplemental oxygen, who develop increasing oxygen requirements or worsening hypoxia (pulse oximetry [spo 2 ] < 95%), should have prompt arterial blood gas analysis with frequent clinical reassessment to guide the requirement for escalation of care and mechanical ventilation. highflow nasal oxygen or noninvasive ventilation may be considered as temporizing measures but are generally discouraged due to the potential for greater aerosolization. in addition, increasing oxygen requirements serve as a marker of disease progression, with increasing risk of atelectasis and pulmonary consolidation. it is recommended to perform early endotracheal intubation in a controlled manner minimizing exposure to health care workers and equipment with airborne precautions in an urgent/emergent situation. 17 one of the frequent complications of patients with covid-19 is acute respiratory distress syndrome the routine use of oxygen for fetal indications should be suspended overall, the use of oxygen for fetal indications is controversial the use of high-flow nasal cannula or facemask oxygen may be an aerosolizing procedure nitrous oxide 9 discuss the relative risks and benefits of nitrous oxide for labor analgesia and consider suspending its use (ards). ventilator management strategies for ards involve lung-protective strategies such as low tidal volumes (6 ml/kg using predicted body weight), plateau pressure <30 cm h 2 o, and the combined use of reduced fio 2 with increases in positive end-expiratory pressure (peep) to maintain a pao 2 of 65-90 mm hg. 18 useful ventilator titration techniques using the ardsnet ventilator protocol can be found in http:// www.ardsnet.org/files/ventilator_protocol_2008-07. pdf.17 pregnant patients have a physiological decrease in paco 2 , and it is recommended to maintain a paco 2 of 28-32 mm hg with ventilation to augment off-loading of oxygen to the fetus. however, the priority is maintaining oxygenation with low tidal volumes and peep, and this strategy may not allow for maintaining the physiologic paco 2 in pregnancy. multidisciplinary discussion should determine the fetal monitoring and delivery plan during mechanical ventilation. neuraxial labor analgesia remains a mainstay of obstetric care even with concurrent covid-19 infection. in fact, early epidural placement is desirable to avoid exacerbation of respiratory symptoms with labor pain and to reduce the likelihood of general anesthesia if intrapartum cesarean delivery becomes needed. the benefits of neuraxial analgesia in the setting of covid-19 pneumonia are 2-fold: (1) for the patient, it will help avoid any exacerbation of respiratory status with intubation and mechanical ventilation and (2) for health care providers, it reduces the risks associated with aerosol exposure and transmission of covid-19 infection during intubation and extubation, if general anesthesia is provided. the risk of covid-19 exposure for the anesthesiologist during neuraxial labor analgesia placement is presumably low, since this is not an aerosol-generating procedure. all health care workers in the room should wear contact (impervious gown and gloves) and droplet (surgical mask and eye protection) precautions. the patient should wear a surgical mask at all times to limit droplet spread, and the number of personnel present during placement of neuraxial labor analgesia should be minimized but with assistance readily available. several strategies may minimize contamination of equipment and covid-19 exposure in anesthesiologists, while also minimizing the consumption of ppe (box 1 and figure) . a parturient who is symptomatic pui, or covid-19 positive, should have a complete blood count before neuraxial analgesia placement. early studies from china suggested that thrombocytopenia may be associated with covid-19 infection; in a cohort of 1099 patients, 36.2% had thrombocytopenia (<150,000 × 10 6 /l). 19 a meta-analysis of 1779 patients with covid-19 infection observed that platelet counts are lower in patients with more severe disease. 20 though less common, a platelet count <100,000 × 10 6 /l can occur; 3 studies of 243 patients reported a total of 6.6% patients with that level of thrombocytopenia. [21] [22] [23] we suggest a platelet count on admission without the need to check serial counts before needle placement unless there is a major change in clinical symptoms. it is generally safe to perform neuraxial procedures at platelet counts of 70,000 × 10 6 /l or above, 24 and, given the rare risk of spinal/epidural hematoma and the much higher risk of respiratory compromise with general anesthesia, neuraxial procedures at even lower platelet counts should be considered. while theoretically possible, the risk of epidural or subarachnoid space seeding with viremic blood, causing encephalitis or meningitis, is exceedingly rare. at the time of this writing, there are 77 pregnant women reported in the literature who received uneventful neuraxial procedures for cesarean or vaginal delivery (4 combined spinal-epidural, 27 epidural, 46 spinal procedures; table 3 ). 6 tray-the required equipment (epidural kit) and drugs should be prepared and brought into the room in a bag before the procedure. 5. have the most experienced anesthesiologist perform the procedure to ensure adequate placement and reduce the risk of accidental dural puncture that may require an epidural blood patch. 6. increase the dosing of neuraxial medications for labor analgesia (eg, increasing the bupivacaine concentration from 0.0625% to 0.1%) or changing the setting of the programmed epidural intermittent bolus (eg, increasing the volume from 5 to 8 ml, or decreasing the interval from every 45 to 30 minutes) or adding neuraxial adjuvants (eg, epidural clonidine) to minimize intrapartum breakthrough pain requiring epidural top-up. 7. round on parturients with video or phone calls into the patient's room for hourly assessments of general status and effects of neuraxial analgesia. spinal-epidural, epidural procedures all are acceptable, and no technique confers more risk that the other based on the literature available. none of the patients experienced neurologic sequelae. current recommendations on the use of nitrous oxide (entonox) for labor analgesia suggest "there is insufficient information about the cleaning, filtering, and potential aerosolization of nitrous oxide in the setting of covid-19." individual labor and delivery units should consider suspending use. 9 additionally, the practice of high-flow oxygen for fetal distress does not improve fetal outcomes and should be suspended due to the risk of aerosolization. 9 anesthesia for cesarean delivery in reports from china, most women with a diagnosis of covid-19 infection underwent a cesarean delivery. 25 in the absence of universal testing and rapid availability of results, covid-19 status may not necessarily be known at the time of cesarean delivery. the baseline failure rate for conversion of labor epidural analgesia to cesarean delivery anesthesia is 5%. 30 urgent intrapartum cesarean delivery represents an important risk factor for failed conversion from intrapartum neuraxial labor analgesia to cesarean delivery anesthesia-therefore, ongoing communication with the obstetricians is crucial to allow safe transfer to the operating room, and adequate time for initiation of surgical block to avoid general anesthesia. 30 to minimize the risk of exposure during urgent endotracheal intubation, airborne protection (n95 respirator mask) is recommended for all providers in the operating room unless the patient is known to be covid-19 negative. a publication from wuhan, china, describing outcomes in 17 covid-19-positive women undergoing cesarean delivery, concluded that "excessive hypotension" occurred in 12 of 14 cases with epidural anesthesia in comparison with the 3 women who had received general anesthesia; however, information about the blood pressure trends and description of the use of vasopressors is not reported. 26 a larger case series of 49 patients receiving spinal anesthesia (45 for cesarean delivery and 4 for orthopedic procedures) was well tolerated with stable blood pressure. 29 in our early experience, maternal hypotension during cesarean delivery with epidural or spinal anesthesia has not been noted, most likely because prevention of hypotension with phenylephrine is part of our routine clinical practice. along with antihypotensive medication, antiemetic medication should also be administered. however, we recommend using an alternative to dexamethasone in a pui or patient with known covid-19 infection given the risk of worsening clinical severity. 14 specific considerations for medication use in pui or covid-19-positive patients during labor, delivery, and the postpartum period are described in table 2 . current understanding is that there is little evidence for vertical transmission in women who develop covid-19 pneumonia in late pregnancy. 2, [31] [32] [33] [34] [35] however, cases of possible in utero infection seem to be emerging including a recent report of a neonate born to a covid-19 infected mother. this suggests in utero infection during the 23 days between maternal infection and delivery 23 days later and supported by elevated immunoglobulin m (igm) antibodies, which are not transferred to the fetus via the placenta. [36] [37] [38] [39] serological testing of virus-specific igg and igm antibodies may alternatively be used if rt-pcr testing is not available or if rt-pcr seems to be yielding a false-negative result. 40 postpartum considerations for parturients with covid-19 infection include adequate management of usual postpartum issues (postpartum hemorrhage, pain, hemodynamic status) as well as judicious fluid management, surveillance for respiratory decompensation, and early involvement of subspecialty care as needed. appropriate isolation of mother and child on the postpartum unit is also recommended. 41 in the setting of postpartum hemorrhage due to uterine atony, carboprost tromethamine (hemabate) followed by endotracheal intubation was reported to have precipitated immediate and prolonged bronchospasm in a patient who was subsequently found to be covid-19 positive. 6, 42 oxytocin and methylergonovine as a second-line choice may be preferred, due to the potential for bronchospasm with carboprost tromethamine (hemabate), and aerosolization of viral particles during bronchospasm management. it has been posited that nonsteroidal anti-inflammatory drugs (nsaids) for management of symptoms suggestive of covid-19 infection may worsen the clinical course of covid-19 patients; however, this remains controversial and robust data are lacking. at this point, for women who are asymptomatic or mildly symptomatic with pain not well controlled with acetaminophen, nsaids can continue to be used, as the alternative of opioids likely poses more clinical risks. 9 there are no reported cases of accidental dural puncture resulting in postdural puncture headache (pdph) in a patient with a covid-19 infection, and consequently, no available guidance. similar to usual care, conservative measures should be initially provided. usual contraindications to the performance of an epidural blood patch (eg, fever, thrombocytopenia, or other coagulation issues) should apply in a covid-19 patient. mitigating the risk of a serious neurologic complications with untreated pdph 43 versus that of viral seeding in the epidural space with an epidural blood patch will require a case-by-case approach. postponing the epidural blood patch is recommended in women who are actively ill. individual assessment of the benefits and risks should be assessed and shared decision-making should be engaged with the patient before proceeding. because a nasal sphenopalatine ganglion (spg) block is likely an aerosol-generating procedure due to the injection/insertion directly into the nasal cavity, it should be avoided to minimize the risk of transmission to health care workers. key points emerging in the past weeks from the literature and our experience in labor and delivery units in the united states are that pregnant women may be asymptomatic on admission in labor, and that symptoms of covid-19 infection may initially be missed or obscured if chorioamnionitis is suspected during labor. although most women with covid-19 infection will not present with pneumonia and respiratory decompensation during labor, escalation of care and advanced critical care resources may become necessary in the postpartum period. in fact, most of the considerations surrounding management of the parturient with suspicion of or known covid-19 infection include not only best strategies to ensure safe care for the parturient but also those to prevent health care worker exposure to sars-cov-2 and contracting covid-19. anesthesiologists are deemed at significant risk of viral exposure during endotracheal intubations of covid-19-infected patients, and all strategies should be applied to avoid general anesthesia in women who are either untested or known to be covid-19 positive. early neuraxial labor analgesia is strongly recommended to ensure availability of neuraxial anesthesia in the event of an intrapartum cesarean delivery, and spinal anesthesia should be provided if needed. if deemed necessary and unavoidable, provision of general anesthesia should follow general recommendations for intubation and extubation in the setting of covid-19-infected patients. the changes in workflow that result from the need to ensure adequate ppe (contact/droplet protection for nonaerosolizing procedures such as [eg, epidural placement] or airborne protection for cesarean deliveries due to the possible conversion to general anesthesia) are considerable and require thorough planning and preparedness. close communication around covid-19 status of all patients admitted to the labor and delivery unit is essential, and anticipation of emergencies is of the essence. overall, providing the best clinical care for pregnant and postpartum women with covid-19 infection also must take into account strategies to prevent health care worker exposure to sars-cov-2 and contracting covid-19. e what are the risks of covid-19 infection in pregnant women? clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records clinical manifestations and outcome of sars-cov-2 infection during pregnancy clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan covid-19 anosmia reporting tool for clinicians covid-19 in pregnancy: early lessons covid-19): cases in the u.s. centers for disease control and prevention institute for health metrics and evaluation (ihme) society for maternal-fetal medicine, society for obstetric and anesthesia and perinatology. labor and delivery covid-19 considerations center for disease control and prevention. interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings. 2020. available at response of chinese anesthesiologists to the covid-19 outbreak the effect of severe acute respiratory syndrome on a hospital obstetrics and gynaecology service sermer m; maternal fetal medicine committee; infectious disease committee. management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (sars) society for obstetric and anesthesia and perinatology. interim considerations for obstetric anesthesia care related to covid19 are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? the maternal early warning criteria: a proposal from the national partnership for maternal safety for the zhongnan hospital of wuhan university novel coronavirus management and research team, evidence-based medicine chapter of china international exchange and promotive association for medical and health care (cpam). a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version) ards in pregnancy clinical characteristics of coronavirus disease 2019 in china thrombocytopenia is associated with severe coronavirus disease 2019 (covid-19) infections: a meta-analysis clinical features of patients infected with 2019 novel coronavirus in wuhan clinical and biochemical indexes from 2019-ncov infected patients linked to viral loads and lung injury clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study multicenter perioperative outcomes group investigators. risk of epidural hematoma after neuraxial techniques in thrombocytopenic parturients: a report from the multicenter perioperative outcomes group neuraxial procedures in covid-19 positive parturients: a review of current reports safety and efficacy of different anesthetic regimens for parturients with covid-19 undergoing cesarean delivery: a case series of 17 patients anesthetic management for emergent cesarean delivery in a parturient with recent diagnosis of coronavirus disease 2019 (covid-19): a case report emergency caesarean delivery in a patient with confirmed coronavirus disease 2019 under spinal anaesthesia spinal anaesthesia for patients with coronavirus disease 2019 and possible transmission rates in anaesthetists: retrospective, single-centre, observational cohort study risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials perinatal transmission of covid-19 associated sars-cov-2: should we worry? clin infect dis lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, china. emerg infect dis an analysis of 38 pregnant women with covid-19, their newborn infants, and maternal-fetal transmission of sars-cov-2: maternal coronavirus infections and pregnancy outcomes clinical analysis of 10 neonates born to mothers with 2019-ncov pneumonia lack of maternal-fetal sars-cov-2 transmission possible vertical transmission of sars-cov-2 from an infected mother to her newborn antibodies in infants born to bothers with covid-19 pneumonia can sars-cov-2 infection be acquired in utero?: more definitive evidence is needed a case report of neonatal 2019 coronavirus disease in china eleven faces of coronavirus disease 2019 coronavirus disease 2019 (covid-19) and pregnancy: what obstetricians need to know lessons learned from first covid-19 cases in the united states major neurologic complications associated with postdural puncture headache in obstetrics: a retrospective cohort study nih nhlbi ards clinical network mechanical ventilation protocol summary key: cord-337572-kx5hihnr authors: ludwig, stephan; zarbock, alexander title: coronaviruses and sars-cov-2: a brief overview date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004845 sha: doc_id: 337572 cord_uid: kx5hihnr in late december 2019, several cases of pneumonia of unknown origin were reported from china, which in early january 2020 were announced to be caused by a novel coronavirus. the virus was later denominated severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and defined as the causal agent of coronavirus disease 2019 (covid-19). despite massive attempts to contain the disease in china, the virus has spread globally, and covid-19 was declared a pandemic by the world health organization (who) in march 2020. here we provide a short background on coronaviruses, and describe in more detail the novel sars-cov-2 and attempts to identify effective therapies against covid-19. i n late december 2019, several cases of pneumonia of unknown origin were reported from china, which in early january 2020 were announced to be caused by a novel coronavirus. the virus was later denominated severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and defined as the causal agent of coronavirus disease 2019 . despite intensive, wide-scale attempts to contain the disease in china, the virus has spread around the world in record time, and covid-19 was thus declared to be a pandemic by the world health organization (who) in march 2020. here we provide a short background on coronaviruses and their origin, and we describe in more detail the novel sars-cov-2 and the efforts thus far to identify effective therapies against covid-19. because they provide care for covid-19 patients and frequently perform procedures that generate aerosol (eg, endotracheal intubation, open suctioning, nebulized treatments), anesthesiologists and intensivists are especially at risk to be exposed to the novel coronavirus, putting them at a very high risk for infection. this is demonstrated by a recent publication showing that health care workers have a higher infection rate compared to the normal population. 1 in addition, given that anesthesiologists and intensivists care for these patients, they should have basic knowledge of sars-cov-2 and the course of covid-19 to effectively treat these patients and to optimally protect themselves. what are coronaviruses and where do they come from? cov are found globally in humans and many different animal species. they are classified in the orthocoronaviridae subfamily (order: nidovirales, subordination: cornidovirineae, family: coronaviridae). 2 cov can be grouped into 4 genera, including α-/β-/γ-/δ-cov and αand β-cov can infect mammals, while γand δ-cov primarily infect birds. cov are enveloped viruses with a lipid membrane derived from the host cell, in which viral surface proteins are embedded. the proteins protruding from the viral membrane (especially the spike [s] protein) give these pathogens their characteristic halo-like appearance under the electron microscope, which has led to the name corona (latin: garland, crown). 3 all cov have in common that their genome is in the form of a single-stranded ribonucleic acid (rna) with positive polarity, meaning that the base sequence of the rna is in the 5′→3′ orientation and corresponds to the later messenger rna (mrna). with a length of 26.4-31.7 kilobases, the genome of cov is the largest rna genome of all known rna viruses. 4 besides a number of nonstructural proteins including the rna-dependent rna polymerase (rdrp), the viral rna encodes 4 essential structural proteins, namely the nucleocapsid (n) protein surrounding the rna genome and 3 membrane proteins: the sglycoprotein, the matrix (m) protein, and the envelope (e) protein. 5 the s-glycoprotein on the surface of cov can attach to the cellular receptor, angiotensinconverting enzyme 2 (ace2) on the surface of human cells. 6 ace2 is found in the lower respiratory tract in late december 2019, several cases of pneumonia of unknown origin were reported from china, which in early january 2020 were announced to be caused by a novel coronavirus. the virus was later denominated severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and defined as the causal agent of coronavirus disease 2019 (covid-19). despite massive attempts to contain the disease in china, the virus has spread globally, and covid-19 was declared a pandemic by the world health organization (who) in march 2020. here we provide a short background on coronaviruses, and describe in more detail the novel sars-cov-2 and attempts to identify effective therapies against covid-19. (anesth analg xxx;xxx:00-00) coronaviruses and sars-cov-2: a brief overview of humans and regulates both the cross-species and human-to-human transmission. 7 cov have a high mutation rate due to their errorprone rdrp, which is responsible for the duplication of genetic information. 8 in addition, homologous recombinations often occur in cov. 9 these properties have contributed to a great diversity of cov in nature, which enables these viruses to infect numerous species. the first coronavirus described was isolated from chicken embryos in 1937, the infectious bronchitis virus (ibv). 10 since then, numerous cov have been detected in a wide variety of animals, including wild animals, farm animals, and pets. they are divided into the genera of the mammalian-associated αand β-cov and the bird-associated γand δ-cov. various cov are important in veterinary medicine such as transmissible gastroenteritis coronavirus (tgev) or porcine epidemic diarrhea virus (pedv) that can cause severe diarrhea in pigs. the spectrum of coronavirus diseases in animals ranges from mild to severe intestinal, respiratory, or systemic diseases. 11 however, there are also many coronavirus infections in animals that do not appear to cause any symptoms. the presence of cov in a wide variety of animal species strongly suggested that these pathogens are of zoonotic origin and are transmitted from wild animals to humans. in particular, the sars pandemic, in 2002-2003, has led to an increasing number of studies in wild animals on all continents. the greatest diversity of cov has so far been detected in bats. 12 this has led to the hypothesis that at least the more recent cov introductions to humans were originally bat viruses that spread to an intermediate animal (eg, the himalayan palm civet for sars-cov and the dromedary camel for the middle east respiratory syndrome [mers]-cov), which then exposed humans to the viruses. however, it can be assumed that there are still some gaps in the detection of zoonotic cov in wild animal populations. in particular, the data situation for economically and/or politically unstable regions of the world is still incomplete. 12 the first human coronaviruses (hcov) were described in the 1960s and were designated hcov-229e and hcov-oc43. 13, 14 there are now 4 endemic hcov known (hcov-229e, hcov-oc43, hcov-nl63, hcov-hku1) that circulate worldwide in the human population. in most cases, these endemic hcov cause relatively mild diseases of the upper and lower respiratory tract and are estimated to account for about a third of all "common colds" in humans. asymptomatic infections have also been described. in some cases, especially in immunosuppressed individuals, children, or persons with existing pulmonary diseases, progression to acute respiratory failure can also occur. 15 the situation completely changed with the appearance of the sars-cov. 16 this virus caused serious human respiratory diseases in china in 2002-2003. approximately 8000 people were affected by the disease at that time, with case fatality rate (mortality rate) of around 9.5%. sars-cov spread could be stopped by the rapid development of a detection method and extensive measures to isolate infected individuals. subsequent studies in wild animals showed that sars-related cov are found in bats and civet cats, hence it was assumed that the virus spread from the civet cat to humans, followed by human-to-human spread. 17 while no human infections with the original sars virus have been reported since 2004, another cov dangerous for humans emerged in 2012. the mers-cov was isolated for the first time from a patient who was hospitalized with acute pneumonia in saudi arabia. 18 by 2019, around 2500 mers-cov infections have been reported in humans, with about a 30% case fatality rate. 14 the main risk area for mers-cov infections is the arabian peninsula. infections were reported to be both through human-to-human transmission and through contact with dromedaries (camels). these animals appear to represent a reservoir for mers-cov. 19 severe acute respiratory syndrome coronavirus 2 at the end of december 2019, china reported the increasing occurrence of pneumonia in the city of wuhan, hubei province. in january 2020, a novel β-cov was identified as the cause. 20 when the virus was first isolated from pneumonia cases in wuhan, china, in december 2019, it was named 2019 novel coronavirus (2019-ncov). as more information and genetic analyses became available, the virus was given the official name of sars-cov-2 by the international committee for taxonomy of viruses, while the who named the disease caused by the virus, covid-19. the genome of the new coronavirus shows similarities to other β-cov found in bats. 20 sars-cov-2 is 96.2% identical to a bat cov ratg13, whereas it shares 79.5% identity to sars-cov. it can therefore be assumed that the virus originally came from bats and has been transmitted over time to other animal hosts and ultimately to humans. although the degree of diversification of sars-cov-2 is lower than that of, for example, influenza viruses, the divergence of 2 prevalent evolvement types of sars-cov-2, l type (≈ 70%) and s type (≈ 30%), was reported. 21 according to this study, strains in l type, derived from s type, are evolutionarily more aggressive and contagious. it is clear now that sars-cov-2 also uses ace2 as a cellular receptor to infect humans. 22 sars-cov-2 is efficiently transmitted from personto-person and has thus able to spread rapidly across all continents in our globalized world. in the resulting covid-19 pandemic, 601,478 people have been infected and 27,961 patients have died so far (as of march 28, 2020, source: johns hopkins university). as an emerging acute respiratory infectious disease, covid-19 primarily spreads through the respiratory tract, by droplets, respiratory secretions, and direct contact. 23 in addition, it has been reported that sars-cov-2 was isolated from fecal swabs and blood, 24 indicating the possibility of multiple routes of transmission. however, this needs further clarification. the current data suggest an incubation period of 1-14 days, in most cases 3-7 days. the virus is highly transmissible in humans and causes severe problems especially in the elderly and people with underlying chronic diseases. covid-19 patients typically present with specific, similar symptoms, such as fever, malaise, and cough. 25, 26 most adults or children infected with sars-cov-2 have presented with mild flu-like symptoms, but a few patients are in critical condition and rapidly develop acute respiratory distress syndrome (ards), respiratory failure, multiple organ failure, and even death. 27 according to a recent report, the common clinical manifestations of covid-19 included fever (88.7%), cough (67.8%), fatigue (38.1%), sputum production (33.4%), shortness of breath (18.6%), sore throat (13.9%), and headache (13.6%). 28 a minor number of patients manifested gastrointestinal symptoms, with diarrhea (3.8%) and vomiting (5.0%). fever and cough were the dominant symptoms, whereas upper respiratory symptoms and gastrointestinal symptoms were rare. the case fatality rate increases with the severity of illness and can reach up to 49% in critically ill patients. 1 unfortunately, no specific therapeutic options are currently available. only supportive measures can be applied at the moment. 29 there is no specific antiviral treatment recommended for covid-19, and no vaccine is currently available. there are several worldwide efforts at developing vaccines against sars-cov-2. however, it is already clear that these vaccination strategies will not be available until 2021 at the earliest and will thus not be of any help for immediate countermeasures. thus, antiviral drugs are urgently needed. new drug licensing as well as repurposing the indications for drugs that are already in clinical use for other diseases would be the most promising options in the short term. several of these drug candidates have been proposed and tested, including the human immunodeficiency virus (hiv) drug lopinavir/ritonavir, the antimalarial drugs chloroquine and hydroxychloroquine, and remdesivir, an inhibitor of rna polymerase with in vitro activity against multiple rna viruses, including ebola. however, the results of many of these initial trials suffer from small sample sizes and/or nonrigorous study design. when lopinavir/ritonavir was tested in a rigorous randomized, controlled, open-label trial involving hospitalized adult patients with confirmed sars-cov-2 infection, no benefit was observed beyond standard care. 30 while a recent trial using hydroxychloroquine was more promising and showed that treatment is significantly associated with viral load reduction/disappearance in covid-19 patients, 31 this study included only a small number of individuals and therefore considered to have very limited validity. preclinical studies suggested that remdesivir (gs5734) could be effective for both prophylaxis and therapy of hcovs infections. 32 this drug was positively tested in a rhesus macaque model of mers-cov infection 33 and has been reported to treat the first case in the united states of covid-19 successfully. 34 accordingly, 2 large clinical trials, nct04252664 for mild/moderate covid-19 and nct04257656 for severe covid-19, were initiated in china, with an estimated end date in early april 2020. similarly, the current lack of valid, rigorous clinical studies has prompted many clinical trials around the world. as one example, europe has begun large joint clinical studies of experimental drugs to treat covid-19. the trials will include 3200 patients in the netherlands, belgium, luxembourg, the united kingdom, france, and spain, to test the clinical efficacy of the antiviral drugs remdesivir, lopinavir/ ritonavir (+/− interferon), and hydroxychloroquine (nct04315948). e characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention available at: https:// talk.ictvonline.org/taxonomy severe acute respiratory syndrome: identification of the etiological agent coronavirus diversity, phylogeny and interspecies jumping coronaviruses: an overview of their replication and pathogenesis structural insights into coronavirus entry ace2 receptor expression and severe acute respiratory syndrome coronavirus infection depend on differentiation of human airway epithelia rates of evolutionary change in viruses: patterns and determinants rna recombination in animal and plant viruses cultivation of the virus of infectious bronchitis animal coronaviruses: what can they teach us about the severe acute respiratory syndrome? ecology, evolution and classification of bat coronaviruses in the aftermath of sars a new virus isolated from the human respiratory tract recovery in tracheal organ cultures of novel viruses from patients with respiratory disease coronaviruses as the cause of respiratory infections identification of a novel coronavirus in patients with severe acute respiratory syndrome hosts and sources of endemic human coronaviruses isolation of a novel coronavirus from a man with pneumonia in saudi arabia mers coronavirus: diagnostics, epidemiology and transmission china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china on the origin and continuing evolution of sars-cov-2 a pneumonia outbreak associated with a new coronavirus of probable bat origin early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan national microbiology laboratory, canada; canadian severe acute respiratory syndrome study team. identification of severe acute respiratory syndrome in canada clinical features of patients infected with 2019 novel coronavirus in wuhan clinical characteristics of coronavirus disease 2019 in china management of critically ill adults with covid-19 a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial the antiviral compound remdesivir potently inhibits rnadependent rna polymerase from middle east respiratory syndrome coronavirus prophylactic and therapeutic remdesivir (gs-5734) treatment in the rhesus macaque model of mers-cov infection washington state 2019-ncov case investigation team. first case of 2019 novel coronavirus in the united states key: cord-265233-v5sq5epy authors: cassorla, lydia title: decontamination and reuse of n95 filtering facepiece respirators: where do we stand? date: 2020-10-15 journal: anesth analg doi: 10.1213/ane.0000000000005254 sha: doc_id: 265233 cord_uid: v5sq5epy the coronavirus disease 2019(covid-19) pandemic created an extraordinary demand for n95 and similarly rated filtering facepiece respirators (ffr) that remain unmet due to limited stock, production constraints, and logistics. interest in decontamination and reuse of ffr, a product class designed for single use in health care settings, has undergone a parallel surge due to shortages. a worthwhile decontamination method must provide effective inactivation of the targeted pathogen(s), and preserve particle filtration, mask fit, and safety for a subsequent user. this discussion reviews the background of the current shortage, classification, structure, and functional aspects of ffr, and potentially effective decontamination methods along with reference websites for those seeking updated information and guidance. the most promising techniques utilize heat, hydrogen peroxide, microwave-generated steam, or ultraviolet light. many require special or repurposed equipment and a detailed operational roadmap specific to each setting. while limited, research is growing. there is significant variation between models with regard to the ability to withstand decontamination yet remain protective. the number of times an individual respirator can be reused is often limited by its ability to maintain a tight fit after multiple uses rather than by the decontamination method itself. there is no single solution for all settings; each individual or institution must choose according to their need, capability, and available resources. as the current pandemic is expected to continue for months to years, and the possibility of future airborne biologic threats persists, the need for plentiful, effective respiratory protection is stimulating research and innovation. p ersistent shortages of filtering facepiece respirators (ffr) to protect health care workers (hcw) 1 during the current coronavirus disease 2019 (covid-19) pandemic 2,3 has driven interest in decontamination and reuse. where do we stand with regard to its efficacy, safety, and role? use of a new, well-fitting n95 ffr has an established safety record that is lacking for decontaminated respirators; therefore, decontamination and reuse remain a crisis management strategy to be considered when conservation strategies including extended use have been exhausted. [4] [5] [6] this review of decontamination methods compliments nathan's infographic waste not, want not 7 with background to the ffr shortage, a review of available literature, updated recommendations, and links to websites expected to contain future guidance. knowledge is growing as relevant studies emerge. consequently, several preprint reports of potential interest that have not yet benefitted from a peer-review process are included with the coronavirus disease 2019 (covid-19) pandemic created an extraordinary demand for n95 and similarly rated filtering facepiece respirators (ffr) that remain unmet due to limited stock, production constraints, and logistics. interest in decontamination and reuse of ffr, a product class designed for single use in health care settings, has undergone a parallel surge due to shortages. a worthwhile decontamination method must provide effective inactivation of the targeted pathogen(s), and preserve particle filtration, mask fit, and safety for a subsequent user. this discussion reviews the background of the current shortage, classification, structure, and functional aspects of ffr, and potentially effective decontamination methods along with reference websites for those seeking updated information and guidance. the most promising techniques utilize heat, hydrogen peroxide, microwave-generated steam, or ultraviolet light. many require special or repurposed equipment and a detailed operational roadmap specific to each setting. while limited, research is growing. there is significant variation between models with regard to the ability to withstand decontamination yet remain protective. the number of times an individual respirator can be reused is often limited by its ability to maintain a tight fit after multiple uses rather than by the decontamination method itself. there is no single solution for all settings; each individual or institution must choose according to their need, capability, and available resources. as the current pandemic is expected to continue for months to years, and the possibility of future airborne biologic threats persists, the need for plentiful, effective respiratory protection is stimulating research and innovation. (anesth analg xxx;xxx:00-00) background n95 ffr play an established role to protect hcw from airborne transmission of infection. 8 while ffr are not superior to surgical masks for protection of hcw from seasonal flu, [9] [10] [11] [12] [13] [14] retrospective studies showed increased protection from severe acute respiratory syndrome coronavirus 1 (sars-cov-1). [15] [16] [17] [18] [19] infectious droplets and aerosols are considered a primary transmission mechanism of the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the cause of covid-19 illness, [20] [21] [22] and data indicate greater resilience in aerosols than sars-cov-1. 23 centers for disease control and prevention (cdc) guidance recommends n95 ffr or higher level respiratory protection in multiple settings for hcw treating potential covid-19 patients. 24 a recent meta-analysis supported an association between ffr and protection from coronaviruses including sars-cov-2. 25 universal masking in a major us health care system was associated with reduced hcw infections. 26 peer-reviewed research comparing the risks and benefits of recycled to single-use ffr is lacking; however, persistent widespread shortages have changed practices. 27 logistics, hoarding, price gouging, theft, faulty or nonexistent products, and fears of government diversion have exacerbated intense competition for new ffr. [28] [29] [30] [31] [32] [33] [34] in 2006, the institute of medicine, now the national academy of medicine, convened a "committee on the development of reusable facemasks for use during an influenza pandemic." highlighting unpreparedness, 2 reports recommended "expeditious research and policy action" to develop personal protective equipment (ppe) designed to withstand decontamination, evidence-based performance standards, and improved coordination among regulatory agencies. 9, 35 multiple government-funded studies of ffr decontamination followed without establishing a scalable, evidence-based solution. 4, [36] [37] [38] [39] [40] [41] [42] [43] a 2019 report to the federal drug administration (fda) concluded, "there is a need for n95 respirators designed for hospital decontamination and reuse to meet the needs of hcw." 39 science to guide n95 ffr decontamination is scarce due to longstanding government and manufacturer recommendations for disposal following single use. [43] [44] [45] there is however a current surge. table 1 contains websites selected as likely sources of relevant future information and guidance. they are hosted by the cdc, 5 a worthy decontamination method must effectively inactivate the target pathogen(s) without impairing particle filtration, effective fit, or safety to a subsequent user. 35 microorganisms have varied resistance to decontamination (≥3-log reduction; 99.9% inactivated) and sterilization (≥6-log reduction; 99.9999% inactivated). 49 enveloped viruses including coronaviruses are among the most susceptible. prions and spores are most resistant. 49 few ffr decontamination efficacy studies have used sars-cov-2. access to biosafety level-3 (bsl-3) laboratories with appropriate protocols and worker protections is required. 50 most measured inactivation of surrogate organisms, including spores, bacteria, sars-cov-1, and flu viruses. thus far, susceptibility of sars-cov-2 appears similar to other single-stranded rna coronaviruses including sars-cov-1. 51, 52 laboratory conditions may not readily replicate real-world factors. multiple studies report that germicidal efficacy of several methods varies substantially depending on the contaminant's solution or medium type and protein content. 53-57 sars-cov-1 and sars-cov-2 also have variable durability in different human fluids, 58 and on different surface types, 52,59 highlighting the value of studies measuring decontamination of ffr fabric. the best-supported methods involve heat, hydrogen peroxide (hp), microwave-generated steam (mwgs), or ultraviolet (uv) light (table 2) . many others are discouraged. gamma irradiation 94 and standard liquid antiseptics including soap and water, ethanol, povidone-iodine, chlorhexidine, and benzalkonium chloride damage ffr electret and/or filter function. 54, 59 household bleach leaves a persistent strong odor. 36, 37, 61, 62, 76, 77 ethylene oxide (eto) is neurotoxic, carcinogenic, and teratogenic and not recommended due to potential residue. 6, 36, 48, 61, 78, 85 decontamination methods time: how long for sars-cov-2? the simplest method to decontaminate ffr is enough time for the contaminant to die. decay is most rapid in the first hours and speeded with increased temperature (t). surface type or medium and relative humidity (rh) are important factors. 52, [58] [59] [60] [61] 63, 94 the number of days until viable sars-cov-2 is undetectable at 22 °c with ~65% rh is 2 on cloth, 3-5 on glass, and 7 on stainless steel (ss) or plastic. 59, 60, 63 detectable amounts persist after 7 days on a surgical mask, 59 7 days in solution, 63 and 14 days in culture medium. 59 shorter surface viability times were reported by fischer et al 52 who measured data and created a model for expected sars-cov-2 decay. on n95 fabric, 3-log reduction at 22 °c required 13 hours, and 6-log reduction required 26 hours. 52 intermediate rh speeds decay of viral aerosols. 94 t <22 °c will help preserve the virus. 52, 59, 60 before considering decontamination and reuse, the cdc currently recommends each hcw be issued 5 ffr, and store each ≥5 days before reuse. 6 to date, there are no definitive studies of viability of sars-cov-2 at room t on any specific n95 respirator model. adequate stock, and clean, dry storage are required for a time-based strategy. required wait is a function of the initial viral load. a minimum wait of 5-7 days at 22 °c is prudent. 6, 47 heat. heat denaturizes proteins, inactivating pathogens. high heat damages ffr materials. investigators seek a t, rh, and time that reliably inactivate target contaminant(s) without functional compromise. intermediate rh facilitates heat inactivation of bacteria and multiple viruses including sars-cov-2. 53, 57, 64, 65 the effect of contaminating medium or fluid on inactivation time 57 may help explain significant variation in sars-cov-1 studies; for example, at 56 °c, the virus was undetectable after 20-90 minutes. 55, 56, 58, 95, 96 a 5-log reduction of sars-cov-2 in serum was measured after 56 °c × 60 minutes. 66 similar reductions in culture media are reported after 56 °c × 30 minutes. and 70 °c × 5 minutes. 59 heat decontamination of n95 fabric has been little studied. fischer et al's 52 study used heat to inactivate sars-cov-2 on n95 fabric discs. using mathematical modeling to extrapolate data, the calculated time to achieve a 3-log reduction using 70 °c dry heat was 48 minutes. a 6-log reduction was calculated to require 96 minutes. 52 daeschler et al 65 most studies report preserved filter function following t ≤100 °c. 36, 37, 52, 61, 62, 65, 67, 68 aerosol filtration was retained in 6 n95 models after dry heat ≤90 °c × 1 hour but deteriorated following t ≥100 °c. 37 using fewer models, recent reports also found preserved n95 filtration following 20 heat cycles ≤100 °c with wide-ranging rh, 62, 67, 68 although high rh with t >85 °c may decrease electret function. 62 fit is generally maintained following heat-based ffr decontamination with some exceptions and model variation. 61, 69, 85 direct contact with metal is avoided. viscusi et al 69 autoclave. autoclave steam heat (typically 121-160 °c under pressure control) is an effective, widely available sterilization method. 97 however, high heat melts polypropylene and many autoclave machines cannot operate <121 °c. in encouraging reports using standard 121 °c × 15 minutes cycles, kumar et al 78 confirmed sars-cov-2 decontamination on 6 n95 models. two studies report good filter function using 1 model each. 76, 77 a third documented good functional results for multiple ffp2 models, a european standard similar to n95. 79 model type appears especially important with standard autoclave. folded ffr may tolerate 3-10 cycles at 121 °c without loss of fit or 0.3 μm particle filtering but some molded styles did not. [77] [78] [79] [80] slight loss of filtration of particles <0.3 μm was observed; however, function remained above regulatory thresholds. 79 ffr decontamination with 121 °c autoclave × 15-17 minutes appears to be a viable option for up to 3 cycles. steris (mentor, oh) developed a customized autoclave cycle for n95 ffr decontamination that limits heat to 65 ± 5 °c × 30 minutes at 50%-80% rh held at 533 mm hg pressure. quantitative filtration and fit testing met niosh standards after 10 cycles. 48 steris received an fda emergency use authorization (eua) to use their software to decontaminate 2 molded and 1 folded ffr models, ≤10 cycles. 45 steam. steam (not autoclave) heat has produced mixed results. liao et al 62 reports that n95 ffr directly exposed to steam failed filtration tests after 5-10 cycles and speculated that moisture affected electret function. other recent reports seek to help individuals wishing to decontaminate 1-2 ffr in low-resource settings. one used steam heat for ffr sealed in plastic bags and tested filter function with aerosolized surrogate coronavirus. 98 another found more effective decontamination of ms2 virus and methicillin-resistant staphylococcus aureus after 5 minutes of steam in a rice cooker than with dry heat at 100 °c × 15 minutes. 99 a recent report documented preserved filtration of a single n95 sample after 10 steam cycles but satisfactory fit testing only up to 3. 68 microwave irradiation and mwgs. mw irradiation uses radiofrequency waves, typically 2450 mhz. an alternating electrical field excites water molecules, generating heat. its germicidal effect may result from mw irradiation and/or heat. 73 although studies of dry mw ffr irradiation reported melted fabric or sparking of metal nose strips, 30, 62, 85 this was a minimal issue with others that included water to absorb energy and provide mwgs. 39, 61, 64, 69, 74 filter function was retained after 3 cycles, although concerns remained about fit. 39,61,64,69 a recent report found that 3 minutes of mwgs resulted in ≥5-log reduction of ms2 phage, a virus more resistant than sars-cov-2. using readily available materials, a single n95 model was effectively decontaminated with preserved fit and filter function after 20 cycles. 75 mwgs appears to be an effective option for individuals in low-resource settings. with all heat methods using t ≤100 °c procedures must avoid cross-contamination, air ffr during cooling to inhibit resistant pathogens, and return each ffr to its original user. model-specific data from studies of heat, autoclave, and microwave (mw) methods are available at n95decon.org. 47 hp-based treatments. hp, h 2 o 2 , is an effective germicide in liquid hp (lhp), vaporized (vhp), gas plasma (hpgp), and ionized (i-hp) gas states. 100 it causes free radical oxidization of dna, rna, and possibly other proteins and lipids. 101, 102 although hp vapor is toxic (osha permissible exposure limit is 1 ppm 103 ), www.anesthesia-analgesia.org anesthesia & analgesia n95 respirator decontamination it degrades to oxygen and water. cellulose and latex materials are avoided as they absorb hp, decreasing concentrations. lhp was studied in preliminary ffr decontamination studies. no visible or filter damage was found following 3 cycles (30 minutes soaking in 3%-6% hp and 16-72 hours drying). 36, 61 this relatively simple method merits further investigation as published studies of fit or required drying time are lacking. all hp studies report effective ffr sterilization of a variety of organisms, including vhp using geobacillus stearothermophilus spores, 40 and hpgp using multiple bacteria, viruses, and spores, 53 and recent reports testing vhp and hpgp with sars-cov-2. 52, 78 regarding filter function and fit, early studies demonstrated greater durability following vhp (3 cycles) than hpgp (2 cycles). 61, 85 testing with manikins battelle (columbus, oh) reported preserved filtration and fit of 1 n95 model after 20 vhp cycles. 40 straps failed before filter function. after 10 vhp cycles, kumar et al 78 found preserved quantitative fit and filter function, using 6 ffr models. wigginton et al 53 demonstrated filter and fit integrity after 10 cycles using 1 ffr model. fischer et al 52 found good filter function after 2 cycles with "acceptable" function after the third, using 1 ffr model. in contrast, filter function has failed after just 1-2 cycles of hpgp in more than 1 study. 53, 78 another recent report of the effects on 0.3 μm particle penetration of 7 ffr decontamination methods found very little change after 10 vhp cycles but damage after the third hpgp cycle, using 3 n95 models. 71 pressure gradient data suggest that all methods damaged filter function by weakening the electret. 71 filter damage following plasma and ionized methods may be related to higher hp concentrations. cramer et al 83 reported on a low concentration i-hp technique (tomi, beverly hills, ca) that is compatible with cellulose-containing ppe. the study found effective sterilization of geobacillus stearothermophilus spores and retention of quantitative fit and filter function after 5 cycles, using 5 ffr models. proprietary hp-based sterilization equipment is prevalent in health care facilities. 46 systems deliver 6%-60% hp in vhp, hpgp, or i-hp forms. hpgpand i-hp-based methods are quicker than vhp. airing times range from a few minutes to 6 hours. a table of multiple proprietary systems is available on the n95decon.org website. 47 fda euas have been granted to 7 companies and 2 universities to use proprietary hp-based systems for ffr decontamination during the pandemic. some use standard equipment. others are mobile, large-scale systems operated by the companies 45 (table 3) . multiple institutions reported on their hp-based programs to decontaminate and reuse ffr during the covid-19 pandemic. 81, 82, 84 news reports highlight calls for independent confirmation of reused ffr safety and fit as internal studies used manikins rather than ffr worn by humans. [104] [105] [106] ultraviolet germicidal irradiation. light in the uv-c range causes molecular damage when absorbed by dna and rna. adequate doses prevent biologic replication. 107 called ultraviolet germicidal irradiation (uvgi), uv-c is commonly used to decontaminate water, air, and surfaces. the delivered dose, a function of energy, area, and time, is measured in joules/ area (j/cm 2 ). low-pressure mercury vapor bulbs are commonly used to deliver uvgi because they emit uv light at 254 nm, very close to the maximally absorbed wavelength for nucleic acids. other sources of uvgi include leds and pulsed xenon lamps. 53, 108 of note, tanning beds, nail salon uv light sources, and sunlight do not deliver uv-c. uvgi decontamination of n95 ffr has been studied for a decade. 39, 41, 64, 86, 87, 95 concerns include widely varied ffr styles, and the potential for attenuation, shadowing, and strap damage. a pathogen must be in the direct path of uv light to be inactivated; therefore, multiple light sources or separate cycles for each side are required. straps do not rest flat and require a secondary antiseptic wipe. 39, 41, 87 viruses are generally more sensitive to uvgi than bacteria or molds; however, sars-cov-1 is among the most resistant viruses to uv-c. 54 , 58 heimbuch and harnish 41 reported on an extensive fda-funded study of uvgi decontamination of ffr using flu and rna viruses, including sars-cov-1 and mers coronavirus. the recommended dose was 1 j/cm 2 , 41 hundreds of times higher than required for hard surfaces. 82 ffr model differences cause significant variation in uvgi efficacy 41, 64, 87, 88 and the dose reaching each layer. 89 adjusting calculations to account for the shape of whole ffr, syphers 89 again found 1 j/cm 2 adequate. mills et al 87 used artificial fluids to assess interference by skin oil or saliva. uvgi remained effective in decontaminating 12 of 15 ffr models and 7/15 straps. fischer et al 52 applied uvgi to a single side of sars-cov-2-contaminated n95 fabric. the dose requirement for a 3-log reduction was 2 j/ cm 2 . two preprint reviews recommend 2-4 j/cm 2 to each side. 54, 90 . added time either before 54 or after 70 uvgi provides additional safety. delivered dose must be verified with calibrated uv-c-specific sensors. resistant pathogens may persist; therefore, protocols must prevent cross-contamination and return each ffr to its original user. filtration preservation is likely a function of lifetime dose. bergman et al 61 documented preserved filtration of 6 n95 models after nearly 5 j/cm 2 . there is little independent research on filter function or fit after a cumulative dose >5 j/cm 2 or 3 "cycles." 61, 69 68 another reports all 6 samples of 3 models failed filter and human fit tests after 10 uvgi cycles, without reported dose. 72 strikingly, 3m reports specific models maintained niosh quantitative filter and fit standards after a cumulative uv-c dose of 100 j/cm 2 , their recommended maximum. 48 chen et al 71 used an assessment of particle penetration and reported decreased filtration following the third uvgi cycle of 1 j/cm 2 using 3 mask models. two are listed by 3m to withstand 100 j/cm 2 . 48 uvgi facilities are widely available 46 and decontamination of n95 respirators has been instituted in multiple us medical centers during the covid-19 pandemic. some have published detailed reports of their protocols, involving dozens of steps. [91] [92] [93] ozone. ozone (o 3 ) gas is an established effective germicide due to its oxidizing properties. in an initial report, ozone was used to inactivate pseudomonas aeruginosa on multiple n95 models with no significant change in filtration for up to 10 cycles. 109 further study is required to establish its promise for ffr. niosh and the cdc moved from normal to contingency to crisis management during the winter of 2020. in early april 2020, the cdc confirmed that 90% of n95 ffr stored in the strategic national stockpile 110 (sns), 11.7 million, had been released to states. 111 this represented 13% of estimated need for 6 weeks and only 1% of estimated need for a yearlong pandemic. 35, 111 some had been stored >10 years. results of ffr fit, filtration, and resistance testing of samples from each of 10 sns sites showed 98% of nearly 4000 tested met niosh standards. 112 cdc recommendations to conserve ffr supplies include minimizing the number of people requiring respiratory protection, using alternate class respirators when feasible, extended use (longer wearing time and/or use with multiple patients), prioritizing use for those at highest risk, and limited reuse. 24 current guidelines authorize health care use of ffr that are not normally used in health care settings, past recommended date for use, and models regulated by other countries. 24 in current cdc guidance, limited decontamination and reuse of ffr is advised for niosh-approved respirators only. ffr manufactured in china are specifically excluded from decontamination under euas. 24, 45 any ffr that was wet, oily, soiled, stained, damaged, deformed, or no longer forms an effective seal to the face must be discarded. 6 the cdc states that the manufacturer should be consulted about any decontamination method and specifically recommends against use of a decontaminated respirator during aerosol-generating medical procedures, "given the uncertainties about the impact of decontamination on respirator performance." 6 specific methods are not currently discussed by cdc. 6 although 3m, a major n95 manufacturer, was not historically supportive of any decontamination or reuse of their products, 43 verification of postdecontamination filtration and fit following multiple decontamination methods is currently provided. 48, 113 3m currently recommends against conventional autoclave, mw, or any method with t >75 °c for their products. 48 us-based manufacturing is encouraged with expedited and prioritized permits 114 along with substantial government contracts. 115 significant 3m and honeywell production increases are underway. [116] [117] [118] future to the degree that regulatory standards specify a required degree of protection, governments are likely to drive innovation of new products designed for hcw. international ffr standards would reduce regulatory barriers that contribute to supply-chain bottlenecks when demand surges. 42,119 more testing using particles <0.3 μm was called the "greatest need for further research" by shaffer and rengasamy. 38 efforts to better protect industrial workers from engineered nanoparticles 120,121 could potentially overlap to protect hcw from nanobiohazards, including viral aerosols. high demand and potential shortages of respiratory protection devices are expected for months to years, [122] [123] [124] and novel airborne pathogens will emerge. the need for available, effective solutions has prompted an international plethora of prototypes including reusable injection molded 125 or 3-dimensional (3d) printable masks for filter inserts, 126,127 a self-disinfecting respirator, 128 nanopore membrane to cover ffr, 129 and 3d-printed frames to improve respirator fit or overcome broken straps. 130, 131 the national institute of health hosts a website to share 3d printable ppe innovations 131 and a recent study documents easy, effective sterilization of 3d printable materials testing many organisms including sars-cov-2. 132 respiratory protection for hcw is of critical importance during the covid-19 pandemic, 133 yet n95 ffr supply remains constrained. conservation strategies including extended use should be used before decontamination and reuse as the risks are lower due to fewer donnings. 4, 6 for individuals with adequate stock, waiting 5-7 days between uses is advised before undertaking any decontamination. 6, 48 manufacturers should be consulted as ffr demonstrate wide model-specific variation in durability following decontamination. 6 large-scale methods require special equipment, substantial resources, and careful organization. best available evidence supports moist heat, low t autoclave, mwgs, and hp-based decontamination as effective methods for sars-cov-2 without causing significant damage to ffr for 2-5 cycles. minimum effective uvgi dose is 2-4 mj/cm 2 . filter function is a factor of cumulative dose and is generally preserved to 5 j/cm 2 . hp-based methods are effective sterilants while the other methods may not inactivate all pathogens and require procedures to prevent cross-contamination and return each respirator to its original user. calibrated verification of each cycle of each method is required whenever possible. questions remain. few peer-reviewed studies comprehensively verified decontamination, filter function, airflow resistance, and fit. laboratory conditions may not fully test realworld variables and decontamination of sars-cov-2 has rarely been measured on n95 materials. fit is a critical vulnerability. failures are frequently reported after more than 3-5 donnings, regardless of method. users must 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critical medical supplies to states. 2020. house committee on oversight and reform niosh tests the effectiveness of ppe in national stockpile. 2020. netec. available at 3m collaborates with decontamination companies for n95 respirators. 2020. 3m company -3m news center niosh conformity assessment letter to manufacturers dod awards $126 million contract to 3m, increasing production of n95 masks. 2020. u.s. department of defense 3m doubled production of n95 face masks to fight coronavirus honeywell further expands n95 face mask production by adding manufacturing capabilities in phoenix n95-face-mask-production-by-addingmanufacturing-capabilities-in-phoenix 3m ceo on covid-19 response: we have a unique and critical responsibility. 3m company -3m news center. available at respirator classification in handbook of respiratory protection -routledge handbooks approaches to safe nanotechnology: managing the health and safety concerns associated with engineered nanomaterials performance of mechanical filters and respirators for capturing nanoparticles-limitations and future direction how the pandemic might play out in 2021 and beyond infection prevention precautions for routine anesthesia care during the sars-cov-2 pandemic shortage could last years without strategic plan, experts warn. healthleaders media injection molded autoclavable, scalable, conformable (imasc) system for aerosol-based protection: a prospective single-arm feasibility study rapid prototyping of reusable 3d-printed n95 equivalent respirators at the george washington university a self-disinfecting face mask for ppe against covid-19 from technion israel: technion -israel institute of technology flexible nanoporous template for the design and development of reusable anti-covid-19 hydrophobic face masks 3d printed frames to enable reuse and improve the fit of n95 and kn95 respirators covid-19 response inactivation of sars-cov-2 and diverse rna and dna viruses on 3d printed surgical mask materials rapid expert consultation on the possibility of bioaerosol spread of sars-cov-2 for the covid-19 pandemic. 2020. login | the national academies press correlation between n95 extended use and reuse and fit failure in an emergency department key: cord-296186-ltdhgtdl authors: verdiner, ricardo e.; choukalas, christopher g.; siddiqui, shahla; stahl, david l.; galvagno, samuel m.; jabaley, craig s.; bartz, raquel r.; lane-fall, meghan; goff, kristina; sreedharan, roshni; bennett, suzanne; williams, george w.; khanna, ashish title: coronavirus disease–activated emergency scaling of anesthesiology responsibilities intensive care unit date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004957 sha: doc_id: 296186 cord_uid: ltdhgtdl in response to the rapidly evolving coronavirus disease 2019 (covid-19) pandemic and the potential need for physicians to provide critical care services, the american society of anesthesiologists (asa) has collaborated with the society of critical care anesthesiologists (socca), the society of critical care medicine (sccm), and the anesthesia patient safety foundation (apsf) to develop the covid-activated emergency scaling of anesthesiology responsibilities (caesar) intensive care unit (icu) workgroup. caesar-icu is designed and written for the practicing general anesthesiologist and should serve as a primer to enable an anesthesiologist to provide limited bedside critical care services. logistics are well positioned to serve on critical care resuscitation/delivery teams under such conditions. the coronavirus disease-activated emergency scaling of anesthesiology responsibilities in the intensive care unit (caesar-icu) program is a joint initiative of american society of anesthesiologists (asa), society of critical care medicine (sccm), anesthesia patient safety foundation (apsf), and society of critical care anesthesiologists (socca) and is intended to create a "survival" guide for the practicing anesthesiologist who may be called on to provide early management and stabilization of covid-19 patients. this narrative review of covid-19 is based on study done by the caesar-icu group and provides basic critical care management principles for the anesthesiologist with an emphasis on relevant organ system effects impacted by covid-19. covid-19 is the systemic manifestation of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus. sars-cov-2 enters human cells via the angiotensin-converting enzyme-2 (ace-2) receptor. it has a binding affinity 10-15 times greater than the sars virus responsible for a smaller outbreak in 2003. 1 the ace-2 receptor is a cell membrane-associated protein that can be found in epithelial (cardiac and renal) cells, endothelial (pulmonary and vascular) cells, and cells of the oral mucosa and nasopharynx ( figure 1 ). when sars-cov-2 binds to the ace-2 receptor, it reduces intracellular ace-2 protein activity. 2, 3 in the heart, ace-2 is involved in endothelial regulation, vasoconstriction, and cardiac function. in the renal system, ace-2 impairment has been implicated in oxidative stress, inflammation, and fibrosis of the renal tissue. 4 the role of ace-2 in the lung is incompletely understood, but increased activity may possibly reduce lung injury in the adult respiratory distress syndrome (ards). 5 although covid-19 may have diverse presentations, respiratory failure is the presentation most relevant to critical care management. patients often present with a dry cough, fever, tachypnea, and dyspnea 6 ; oxygen saturations <90% are common; and patients are surprisingly asymptomatic for their degree of desaturation. 7, 8 alternative diagnoses include pneumonia, congestive heart failure (chf), iatrogenic volume overload, or pulmonary embolism; however, these should not rule out covid-19 without testing. pulmonary embolism occurs commonly in conjunction with covid-19, 9 even in patients receiving prophylactic or therapeutic anticoagulation, suggesting an underlying hypercoagulable state. 10 figure 1 . the role of ace-2. this figure illustrates the conversion of angiotensin i and ii into angiotensin (1-7) which has organ-protective effects by ace-2 cleavage. angiotensin ii in the absence of ace-2 demonstrates increased cytokine release and could lead to end-organ injury. ace-2 indicates angiotensin-converting enzyme-2. in a suspected covid-19 patient, personal protective equipment (ppe) should include precautions against contact, droplet, and, in the case of aerosolizing procedures (eg, transesophageal echocardiogram examinations, endoscopy, extubation, tracheostomy, chest compressions, and nebulizer treatments), 11 airborne spread. avoiding bronchoscopies and sputum cultures will reduce aerosolization. although covid-19 lung injury clinically resembles bilateral pneumonia, the specific pathophysiology remains controversial. 12, 13 in some patients, lung compliance is low, leading to lower tidal volumes for the same inspiratory airway pressure. 14 this reduced compliance is likely due to alveolar exudates that reduce the number of viable alveoli. such a presentation resembles the ards and can be stratified based on pao 2 /fio 2 ratio of <300 = mild disease and <100 = severe. [14] [15] [16] in some patients with covid-19, lung compliance can be normal. 17, 18 ventilation strategies many patients with covid-19 respiratory failure do not require immediate intubation. efforts to avoid intubation and mechanical ventilation should be balanced against the risk of nosocomial transmission. the use of high-flow nasal cannula (hfnc) carries a poorly quantified but likely higher risk of aerosol generation than lower-flow forms of oxygen supplementation 19 ; its risk compared to noninvasive positive pressure ventilation (nippv), 20 or intubation and mechanical ventilation, are also unknown. some health care organizations have recommended against noninvasive ventilation due to the risk of covid transmission [21] [22] [23] [24] given these same risks. self-proning of awake patients receiving oxygen by nasal cannula or hfnc, while minimally described in the literature, 25 is low risk and may improve oxygenation. 26 a core principle of ards management is control of fluid balance to reduce the contribution of pulmonary edema to gas exchange abnormalities in the injured lung. although data in covid-19 are lacking, limiting fluids has improved outcomes in other forms of ards 27 and is used in covid-19 management to improve gas exchange. under such conditions, monitoring for adequacy of oxygen delivery and end-organ damage due to hypovolemia is needed. considerable variability currently exists among centers with respect to when patients with covid-19 respiratory failure should be intubated. factors to consider include the time required to don ppe and the rapidity of deterioration in gas exchange. for covid-19 intubations, video laryngoscopy with appropriate ppe (contact, droplet, and airborne), ideally in a negative pressure environment and with the most experienced personnel performing the laryngoscopy, may reduce the likelihood of health care infection ( figure 2 ). bag mask ventilation may also increase the risk of aerosolization. in many centers, central line and arterial line insertion are performed in the same encounter to reduce donning/doffing episodes for clinicians and radiology staff. once intubated, lungprotective ventilation is the cornerstone of ards management, and ardsnet-based principles of ventilation should be followed. key priorities are as follows: • volume control modes of ventilation are easiest to manage clinically as they deliver a prespecified tidal volume rather than an inspiratory flow and do not allow the patient to increase tidal volumes. small tidal volumes combined with high peep and hypercarbia may contribute to air-hunger and deep sedation may be required (see neurologic considerations section for drug choices and strategies). auto-peep can cause severe reductions in cardiac output and may do so when expiratory gas flow does not reach 0 l/s before the next breath. in such patients, disconnecting the ventilator can prevent cardiac arrest. if the ventilator must be disconnected for a covid-19 patient, caregivers should be careful to limit aerosolization as much as is possible (ie, disconnecting from the circuit in a way that leaves any filtering device in place on the endotracheal tube). instead, if clinically appropriate, shortening inspiratory time, treating bronchospasm if present, and increasing sedation may resolve the issue. other than lung-protective ventilation and maintaining a negative fluid balance, 27 few therapies have been successful in managing ards. 15 prone positioning may improve outcomes 28 care during mechanical ventilation includes stress ulcer prophylaxis, spontaneous awakening trials coupled with spontaneous breathing trials (sat/sbt) where safe, and the use of bundled care to prevent ventilator-associated pneumonia (vap) and sepsis. the importance of deep venous thrombosis (dvt) prophylaxis deserves emphasis, given the reported hypercoagulable state 10 and high rate of dvt 9 in patients with covid-19. there is some evidence that elevated d-dimer levels may be associated with poor prognosis. 31 it is believed that sars-cov-2 may facilitate both endothelial activation of von willebrand factor and factor viii as well as complement-mediated microvascular injury and thrombosis. 32 both pathways would contribute to a hypercoagulable state. because of the reduced mortality associated with anticoagulation in severe covid-19 cases, some authors have recommended therapeutic doses of anticoagulation. 33, 34 in the absence of shock, fluid therapy should be managed conservatively to minimize the contribution of pulmonary edema to gas exchange and lung compliance. 35 the inhaled pulmonary vasodilator (ie, nitric oxide) can be trialed to reduce v/q mismatch and shunt but can worsen hypotension or hypoxemia. 36 use of methylprednisone for ards, in general, and for covid-19, specifically, remains controversial. [37] [38] [39] in cases of refractory hypoxemia and hypercarbia, extracorporeal membrane oxygenation (ecmo) can be considered (see extracorporeal life support considerations section). 40 in light of increased mortality in elderly patients and those who require intubation, end-of-life care issues should be addressed. when the respiratory status improves, the most common approach to ventilator weaning is daily sat/sbt to assess readiness for extubation. patients with covid-19 often require prolonged ventilation and extubation failure can worsen outcomes. 41 a daily sbt is usually coupled with an sat and should last for 30-60 minutes with institution-specific pressure support settings (usually 5/5 cm h 2 o). patients with covid-19 should be extubated with the same ppe required for intubation. 42 although data are lacking in patients with covid-19, extubating to hfnc can decrease reintubation and should be considered if resources are sufficient. 43, 44 the same ppe required for intubation should be utilized by health care workers during extubation. the dramatic spread of covid-19 has galvanized research institutions to find effective solutions to minimize the societal impacts of this disease. the surviving sepsis campaign covid-19 panel composed guidelines based on an extensive review of the literature. 45 47 without proper infection control, those providing treatment can clearly become transmitters of the disease itself. laboratory diagnosis and specimen retrieval enable confirmation of the suspected diagnosis as well as appropriate de-escalation of treatment and resources like broad-spectrum antibiotics, airborne precautions, and negative pressure isolation. typical specimen samples will include nasal swab if the patient is not intubated and tracheal aspirate if intubated. 45 the last of the principles-supportive careencompasses a range of issues in patients with covid-19. with regard to systemic steroids, the panel reserved administration for ventilated patients with severe ards, but on a case-by-case basis. empiric antibiotics were recommended because bacterial coinfection may be difficult to recognize and diagnose (table) . daily assessment for de-escalation, duration, and antibiotic spectrum was recommended based on microbiology specimens. in regard to fever management, acetaminophen was viewed as a patient comfort strategy. for the patient presenting in high output septic shock, conservative and judicious resuscitation with crystalloids was preferred over liberal fluid resuscitation due to lung injury associated with a concomitant capillary leak syndrome and poor outcomes with higher cumulative fluid balances in ards. if a vasoactive agent was needed, the panel recommended norepinephrine as the preferred first-line vasoactive agent. vasopressin was the second-line agent if norepinephrine alone did not reach the targeted mean arterial pressure goal of 65 mm hg. dobutamine was the recommended inotropic agent when cardiac dysfunction was present. hydrocortisone at 200 mg/d was recommended in refractory shock. 45 angiotensin ii, though not recommended by the sccm guidelines, may have a potential therapeutic role beyond supporting the map based on the speculative hypothesis of downregulation of ace-2 receptors, saturation of and competitive inhibition of ace-2 enzyme activity. 48, 49 insufficient data exist to strongly support any single approach to antiviral therapy. the panel did not recommend ivig without adequate titers of neutralizing antibodies. recombinant interferon-beta (inf-beta) inhibits sars-cov-2 in cell cultures, and studies by the world health organization (who) are ongoing. currently, trials of convalescent plasma are also underway. lopinavir/ritonavir is still being investigated by the who. remdesivir-a prodrug analog of adenosine-results in premature rna chain termination, and trials in mild, moderate, and severe covid-19 patients are ongoing. hydroxychloroquine has received attention in the lay-press and may be a more potent inhibitor of sars-cov-2 in vitro compared to chloroquine. although randomized trial data are lacking, dosing regimens of 400 mg bid loading followed by 200 mg bid for 4 days. tocilizumab is an anti-interleukin-6 (il-6) immunoglobulin. this drug was originally used in both rheumatology and oncology for its effects on hemophagocytic syndrome. its effects on reducing cytokine concentrations and acute phase reactants has prompted its consideration in severe covid-19 where a hyperinflammatory state (cytokine release syndrome) is known to be a prominent feature. 50 as previously mentioned, sars-cov-2 virus entry target is the ace-2 receptor. the presence of this receptor in cardiac epithelial cells facilitates myocardial damage by the virus via inhibition of the intracellular activity of the ace-2 protein. 48, 51, 52 in the setting of covid-19, a 7.2% incidence of acute cardiac injury and 16.7% incidence of arrhythmias have been reported. 1 the presentation of myocardial injury in covid-19 includes elevated troponin and c-reactive protein, st changes, t-wave inversion, arrhythmia, heart failure, reduced ejection fraction, angina, and cardiomegaly on chest x-ray. trending these markers helps plot an overall cardiac course. additionally, il-6 levels are used as an indicator of systemic dysregulation of proinflammatory mediators (cytokines, oxygen-free radical, and coagulation factors). in covid-19, early detection and mitigation of such a cytokine "storm" may reduce end-organ damage (a clinical trial is ongoing). 52 in the absence of rapid il-6 levels, clinicians have also used the h score to assess excessive immune reactivity. 53, 54 if elevated, tocilizumab may be used. 54, 55 electrocardiography not only helps monitor arrhythmias and st changes but can also help detect drug-related prolongation of qtc. 55 hydroxychloroquine/chloroquine and azithromycin are commonly used treatments for covid-19. both agents cause prolongation of qtc. 56, 57 when the qtc is greater than 500, the risk of torsade de pointes (polymorphic ventricular tachycardia) is higher, which can be avoided if the medications are either stopped or the doses reduced. echocardiography may also distinguish between covid-19-related acute coronary syndrome (acs) and myocarditis. the hypoxia of ards, increased metabolic demand, and end-organ hypoperfusion can cause myocardial ischemia, which presents on echo as regional hypokinesis. if severe, overall ejection fraction may be depressed, and echo may reveal isolated left ventricular or right ventricular dilation. the typical acs management protocol should be followed with the caveat that the effect of beta-blockers (eg, metoprolol) may be enhanced by concomitant use of either hydroxychloroquine and chloroquine due to inhibition of cyp2d6. in contrast to the regional hypokinesis of myocardial ischemia, hypokinesis due to covid-19-induced myocarditis is global. both ventricles are dilated and contractility is reduced (figure 3 ). on echocardiography, the ventricles will appear round in the 4-chamber view instead of the typical oval shape that tapers at the apex. in the presence of covid-19, this finding is highly suggestive of myocarditis. 56, 58, 59 if the left ventricular ejection fraction falls below 20%, anticoagulation should be considered to prevent spontaneous left ventricular thrombus formation. steroids and nonsteroidal anti-inflammatory drugs (nsaids) are not recommended for covid-19 patients, in general, 60 and particularly those with impending or ongoing myocardial injury and may worsen heart failure. 61, 62 data are insufficient to support stoppage of ace inhibitors and ace receptor blockers. 63 if the h score or c-reactive protein level is significantly elevated, an il-6 inhibitor should be considered. initiating ecmo is an option for some covid-19 patients, depending on institutional expertise and resource availability. in the 2018 ecmo to rescue lung injury in severe ards (eolia) trial, 64 60-day mortality was not significantly lower with patients randomized to receive ecmo, but the trial was limited by a high rate of crossover from the control to the ecmo group. 40, 64 a recently published pooled analysis of 17 covid-19 patients treated with ecmo reported a high mortality (94.1%), 65 although in other emerging reports, survivors have been reported. 66 given the overwhelming presentation of patients during the covid-19 pandemic, starting new ecmo centers is not advised and decisions to initiate ecmo must be subject to considerable thought and judgment 66 and each patient should be considered individually with respect to risks, benefits, and available resources. for both venovenous (vv) and venoarterial (va) approaches, current guidelines 67,68 endorse use of ecmo for patients with severe disease and high predicted mortality. experience with non-covid use of ecmo suggests that younger patients with minor or no-comorbidities should remain the highest priority for ecmo. 66, 69 use of ecmo in covid-19 patients with a combination of advanced age (>60 years old), multiple comorbidities, or multiple organ failures should be rare. readers are encouraged to review ecmo management materials available at the asa caesar resource library (https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information/caesar) and the extracorporeal life support organization (https:// www.elso.org/resources/guidelines.aspx). many patients in the icu with covid-19 will require mechanical ventilation, which typically obligates them to sedation. the abcdef bundle is helpful to determine sedation needs and is implemented in the following fashion: assess, prevent, and manage pain, both sat and sbt, choice of analgesia and sedation, delirium: assess, prevent, and manage, early mobility and exercise, and family engagement and empowerment. 70 delirium screening should be performed daily in patients who are able to participate, as delirium increases mortality and should be prevented. 71 the confusion assessment method for the icu (cam-icu) is commonly used to screen patients for delirium and is validated for patients receiving sedation and on mechanical ventilation. 72 sedation should be titrated using a clinical scale such as the richmond agitation and sedation scale (rass) score ranges from +4 (combative), 0 (awake and calm), to −5 (comatose), and a reasonable goal would be a range of 0 to −2. 73 such scales are preferred over eeg monitoring. 74 deeper sedation is often required to tolerate high peep ventilator settings and for patients who will require paralysis. strict ventilator synchrony (eg, not overbreathing or "double-stacking") is important to avoid increased oxygen consumption and barotrauma. dexmedetomidine should not be used without other amnestic medication in patients requiring neuromuscular blockade, and bispectral index (bis) monitor might be suited to such patients. 74 of note, sevoflurane and propofol interact with chloroquine and hydroxychloroquine to increase the likelihood of qtc prolongation. remdesivir does not have known interactions with any major anesthesia drugs. propofol infusion syndrome should always be considered if sudden acidosis occurs after prolonged infusion, particularly in younger patients. 75 furthermore, pain control with iv infusions and enteral regimens are both acceptable. half of icu patients will have pain, and multimodal regimens can be used even when patients are mechanically ventilated (eg, acetaminophen, gabapentinoids, transdermal lidocaine, tramadol, muscle relaxants [methocarbamol, etc], and opioids). 76 although epidemiologic data are lacking, and given noted concerns about hypercoagulability, stroke may be a relatively common complication of covid-19. 77 a sudden change in mental status or acute onset of focal neurologic changes not explained by drugs should trigger a differential diagnosis that includes stroke and hemorrhage. the national institute of health stroke scale (nihss) is performed for all patients suspected of stroke, and a head ct should be ordered when a stroke is suspected. 78 in many institutions, a "code stroke" pathway is present which mobilizes the neurology team and makes the patient a top priority for a rapid, definitive diagnostic evaluation. 79 ischemic strokes and subarachnoid hemorrhage (after clipping/coiling) may require a higher blood pressure for several days to prevent permanent loss of function while hemorrhagic strokes require tighter blood pressure control, commonly with an infusion. special care should be given to patients with status epilepticus, spinal cord injuries, and tbi, and hyperventilation cannot be used for anything beyond short-term, emergent control of catastrophic elevations in intracranial pressure (ie, during active herniation). acute kidney injury (aki) is common in critically ill adults with an incidence of 57.3% in 1 large, international epidemiologic study. 80 aki and the duration thereof are independently associated with poor clinical outcomes. 81, 82 early published covid-19 data suggest that aki develops in approximately 15% of inpatients and 50% of nonsurvivors. 83 in another study examining critically ill adults, 29% had aki. 84 aki has likewise been associated with adverse outcomes in patients with covid-19. 85, 86 in 1 small series of critically ill adults from washington state, 4 of 21 patients developed acute kidney failure. 87 anecdotally, the authors have personally found that approximately 20%-30% of mechanically ventilated covid-19 patients require renal replacement therapy (rrt) in their institutions. the pathophysiology of aki in covid19 is not yet definitively established. sars-cov-2 binds with ace-2 receptors, which are expressed in the kidneys. both podocytes and proximal straight tubule cells have been identified as viral hosts, 88 possibly explaining the high incidence of observed proteinuria. 85 pathologic findings have been consistent with acute tubular necrosis (atn). 89 aside from direct cytopathic effects, ards and shock may also contribute to atn in severely ill patients. prerenal etiologies should be considered early in the disease course in patients who have had anorexia or severe gi manifestations. for critically ill adults with covid-19, the authors recommend that the routine diagnostic workup include urine analysis, spot urine studies for electrolytes, protein, and microalbumin-to-creatinine ratio in addition to routine serum chemistries. for patients with aki, urine microscopy may be helpful, and the diagnostic workup should parallel that of aki in critically ill adults. similarly, the care of covid-19 patients with perturbations in renal function should center around foundational supportive care: avoidance of renal insults (ie, nephrotoxins and hypotension), resuscitation or diuresis to euvolemia, correction of electrolyte and acid-base perturbations, and nutritional optimization. 90 patients with covid-19 demonstrate hypercoagulability 10 which may increase the risk of clotting of continuous renal replacement therapy (crrt) filters. appropriate temporary dialysis catheter placement and position are important from an access quality standpoint, and optimization of the dialysis prescription (eg, high blood flows and predilution replacement fluid) may help to extend filter life. one potential solution is staged anticoagulation for patients on crrt: regional citrate anticoagulation, followed by escalation to prefilter heparin administration with serum monitoring of heparin levels per local protocol, and then finally consideration of alternative systemic anticoagulants (ie, direct thrombin inhibitors). potential local or national shortages of citrate, calcium, and/ or systemic anticoagulants may influence the optimal approach. hospitals should also develop staged rrt surge plans, which might include mixed crrt durations with machine redeployment, various prolonged intermittent rrt approaches, and/or acute peritoneal dialysis. 91 like other critically ill patients, those with covid-19 are at risk of dysregulated glucose. targeting blood glucose levels <180 mg/dl utilizing subcutaneous or intravenous insulin and avoiding oral hypoglycemics are reasonable. 92, 93 aggressive treatment of hypoglycemia with 50% dextrose or continuous infusion of dextrose-containing crystalloids will avoid complications of hypoglycemia. severe hyperglycemia may be associated with diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome. both processes result in osmotic diuresis and electrolyte wasting, and therefore require volume resuscitation and vigilant correction of electrolyte imbalances, along with administration of insulin. 94 measured sodium values may be falsely low in the presence of hyperglycemia and require corrected calculation. insulin infusions require hourly glucose checks and are resource demanding, so subcutaneous regimens should be used if possible. nutritional considerations are critical to the management of patients with ards, in general, and a detailed resource can be found on the caesar-icu website https://bit. ly/2vpcgmi. critically ill patients may have abnormal thyroid function tests (eg, decreased t3) in the absence of true thyroid dysfunction (ie, euthyroid sick syndrome), and thyroid hormone supplementation is not warranted. 95, 96 patients with chronic hypo-or hyperthyroidism should continue their home thyroid medication regimens with minimal interruptions. rarely, patients with untreated thyroid dysfunction may develop life-threatening thyroid disorders (eg, myxedema coma, thyroid storm), which warrant immediate consultation with an endocrinologist. patients with primary or secondary (eg, chronic prednisone use) adrenal insufficiency are at significant risk for adrenal crisis. empiric stress dose steroid replacement (eg, hydrocortisone 50 mg every 6 hours) should be considered in these patients for the duration of their critical illness. 97 patients without known adrenal insufficiency may develop relative adrenal insufficiency during critical illness, which presents commonly as refractory hypotension unexplained by sepsis or cardiac dysfunction. random cortisol levels and acth stimulation testing are not routinely recommended; rather empiric use of stress dose hydrocortisone (as above) should be considered in patients with profound distributive shock and inadequate response to vasoactive medications. [97] [98] [99] steroids are not recommended for the treatment of hypoxia and ards precipitated by viral pneumonia, as they may prolong viral clearance and increase mortality. 100 steroids can be considered for patients with covid-19 who develop refractory shock or have underlying adrenal insufficiency. under normal nonpandemic circumstances, the general principles of medical ethics apply, as described by beauchamp and childress. 101 these include patient autonomy, beneficence, nonmaleficence, and justice. however, under resource-limited circumstances such as in the covid-19 pandemic, the utilitarian philosophy of social justice (the most good for the greatest number of people) becomes important. ethical issues may occur when allocating icu beds, ventilating patients, withdrawing life-supportive treatment, starting experimental treatments, or resuscitating patients suffering from cardiac arrest. these decisions will require (1) a hospital policy, (2) consultations with the broader icu team, and (3) rapid ethics consultations. 102 such decisions should consider (a) the age and premorbid status of the patient, (b) the severity and prognosis of the disease, (c) the severity of the shortage of resources (supply/demand proportion), and (d) the stage of the pandemic (whether the overburdened phase has been reached). 103 ways of moving forward should include the following: 105 other specific strategies may ease the impact of these complex decisions on caregivers and families, but all stem from the underlying recognition that the patients are someone's loved one who may be denied some aspect of care (eg, an icu bed or ventilator). the sharing of empathy and compassion and having conversations early in the clinical course may be helpful, particularly for patients who are elderly or at high risk. emphasizing comfort care measures may allay concerns that caregivers are abandoning patients who are not being offered other critical care measures, and palliative care teams can be invaluable in this setting. it is also critical for clinicians to make use of available support system resources, as complex end-of-life issues will take a psychological toll on caregivers. the current coronavirus pandemic is unprecedented in the modern medical era and covid-19 is an entirely new disease. covid-19 is remarkably transmissible and can render patients critically ill in a very short period of time. the covid-19 pandemic may require health care systems to adapt to volumes of critically ill patients that exceed their capacity, and nonintensivist anesthesiologists are rapidly being deployed in their critical care management. the respiratory care of these patients should closely mimic the care for ards patients without covid-19, with the caveat that some patients may not have the typical poor compliance of ards, and that many patients require extended ventilatory support. because covid-19 may affect the heart and affected patients may be hypercoagulable, myocardial injury has been reported and can be severe. in addition to antiviral protocols, the use of broad-spectrum antibiotics to cover coinfection should be considered, particularly for patients in shock. many critically ill patients with covid-19 will require sedation for mechanical ventilation, and the 2018 sccm guidelines are appropriate for the care of these patients. most importantly, sedation should be targeted to a desired effect, including ventilator synchrony, with interruptions daily if possible, and patients will often require deep sedation if they are severely hypoxemic or require neuromuscular blockade. aki is a common consequence of covid-19, either due to atn or hypotension. the hypercoagulability of covid-19 patients may lead to increased clotting of crrt filters but the nature of this hypercoagulability is not defined. the need for glycemic control is not unique to patients with covid-19, but because of the need to limit room entry, patients who might otherwise be managed with an insulin infusion should be first trialed on a subcutaneous regimen. the role of steroids has been raised for both lung injury and hemodynamic aspects of care of covid-19 patients, but the best evidence for steroids is for the treatment of septic shock refractory to pressors and for adrenal insufficiency. finally, because of the expected high mortality of critically ill patients, and the possibility that the number of patients will exceed the resources available, ethical considerations must be a part of health care systems' response plans. systems, not individual clinicians, should develop plans for how to triage and ration care requiring limited resources (eg, ventilators, icu beds, blood products), and, perhaps more important than many of the medical strategies described above, clinicians must address the end-of-life concerns of patients who have a high likelihood of dying of this disease. e cryo-em structure of the 2019-ncov spike in the prefusion conformation angiotensin-converting enzyme 2 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respiratory support of suspected or confirmed covid-19 patient: non-invasive ventilation, high flow nasal cannula oxygen, invasive ventilation and patients with tracheostomies oxygenation and ventilation of covid-19 patients prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study critical care western research group. patient self-proning with high-flow nasal cannula improves oxygenation in covid-19 pneumonia national heart, lung, and blood institute acute respiratory distress syndrome (ards) clinical trials network. comparison of two fluid-management strategies in acute lung injury proseva study group. prone positioning in severe acute respiratory distress syndrome neuromuscular blockers in early acute respiratory distress syndrome the national heart, lung, and blood institute petal clinical trials network. early neuromuscular blockade in the acute respiratory distress syndrome abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy severe covid-19 infection associated with endothelial activation fluid management in acute respiratory distress syndrome: a narrative review salvage therapies for refractory hypoxemia in ards risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial steroids are part of rescue therapy in ards patients with refractory hypoxemia: we are not sure extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and posterior probability of mortality benefit in a post hoc bayesian analysis of a randomized clinical trial independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation intubation and ventilation amid the covid-19 outbreak effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china summary of a report of 72 314 cases from the chinese center for disease control and prevention coronavirus disease 2019 (covid-19) in italy covid-19 and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers what is the evidence? covid-19 and the raas-a potential role for angiotensin ii? effective treatment of severe covid-19 patients with tocilizumab effect of angiotensin-converting enzyme inhibition and angiotensin ii receptor blockers on cardiac angiotensin-converting enzyme 2 angiotensin ii up-regulates angiotensin i-converting enzyme (ace), but down-regulates ace2 via the at1-erk/ p38 map kinase pathway development and validation of the hscore, a score for the diagnosis of reactive hemophagocytic syndrome available at: http:// saintantoine.aphp.fr/score hlh across speciality collaboration, uk. covid-19: consider cytokine storm syndromes and immunosuppression cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (covid-19) pandemic coronaviruses and the cardiovascular system: acute and long-term implications viral myocarditis: potential defense mechanisms within the cardiomyocyte against virus infection nonbacterial myositis non-steroidal anti-inflammatory drugs and covid-19 nonsteroidal antiinflammatory drugs as a trigger of clinical heart failure nonsteroidal anti-inflammatory drugs and the heart renin-angiotensin-aldosterone system inhibitors in patients with covid-19 extracorporeal membrane oxygenation for severe acute respiratory distress syndrome poor survival with extracorporeal membrane oxygenation in acute respiratory distress syndrome (ards) due to coronavirus disease 2019 (covid-19): pooled analysis of early reports initial elso guidance document extracorporeal life support organization extracorporeal life support organization. guidelines for adult respiratory failure outcomes of venovenous extracorporeal membrane oxygenation when stratified by age: how old is too old? caring for critically ill patients with the abcdef bundle: results of the icu liberation collaborative in over 15,000 adults outcome of delirium in critically ill patients: systematic review and meta-analysis delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (cam-icu) the effect of sedation protocol using richmond agitation-sedation scale (rass) on some clinical outcomes of mechanically ventilated patients in intensive care units: a randomized clinical trial clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the icu propofol infusion syndrome: a structured literature review and analysis of published case reports metody oceny natężenia bólu u dorosłych xxx xxx • volume xxx • number xxx www.anesthesia-analgesia.org pacjentów oddziałów intensywnej terapii -polska wersja językowa narzędzia cpot (critical care pain observation tool) i bps (behavioral pain scale) large-vessel stroke as a presenting feature of covid-19 in the young baseline nih stroke scale score strongly predicts outcome after stroke: a report of the trial of org 10172 in acute stroke treatment (toast) in-patient code stroke: a quality improvement strategy to overcome knowledge-to-action gaps in response time epidemiology of acute kidney injury in critically ill patients: the multinational aki-epi study longterm risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis the prognostic importance of duration of aki: a systematic review and metaanalysis clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study kidney disease is associated with in-hospital death of patients with covid-19 acute renal impairment in coronavirus-associated severe acute respiratory syndrome characteristics and outcomes of 21 critically ill patients with covid-19 in washington state identification of a potential mechanism of acute kidney injury during the covid-19 outbreak: a study based on single-cell transcriptome analysis human kidney is a target for novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection management of acute kidney injury: core curriculum 2018 covid-19 and the inpatient dialysis unit nice-sugar study investigators. intensive versus conventional glucose control in critically ill patients glucose management in critically ill adults and children hyperglycemic crises: diabetic ketoacidosis (dka), and hyperglycemic hyperosmolar state (hhs) thyroid function in critically ill patients euthyroid sick syndrome. statpearls guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (circi) in critically ill patients (part i): society of critical care medicine (sccm) and european society of intensive care medicine (esicm) 2017 van den berghe g. new insights into the controversy of adrenal function during critical illness corticosteroids for treating sepsis in children and adults. cochrane emergency and critical care group treating covid-19-off-label drug use, compassionate use, and randomized clinical trials during pandemics principles of biomedical ethics who should receive life support during a public health emergency? using ethical principles to improve allocation decisions ethical decisions in times of disaster: choices healthcare workers must make the ethics and reality of rationing in medicine recommendations for end-of-life care in the intensive care unit: the ethics committee of the society of critical care medicine key: cord-274819-xp5q9f0r authors: lai, yu yung; chang, chia ming title: a carton-made protective shield for suspicious/confirmed covid-19 intubation and extubation during surgery date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004869 sha: doc_id: 274819 cord_uid: xp5q9f0r nan to the editor w ith the widespread coronavirus disease 2019 (covid-19) pandemic, respiratory treatment and supportive care for the patients have become an important part of standard treatment. endotracheal intubation is an essential step in airway management. during the intubation process, the patient's cough may produce secretions and become a source of transmission to infect the caregivers and surrounding working area. many intubation precautions and devices have been proposed, 1 including medications, personal protective equipment (ppe), and barrier enclosure. a barrier enclosure has recently been proven to effectively minimize the spread of patients' droplets and aerosols during intubation. 2 however, in the scenario of suspicious/confirmed covid-19 patients who need to undergo emergency surgery, extubation and emergence cough after general anesthesia are another potential source of transmission, and might contaminate the operating room. the importance of covid-19 extubation should be emphasized to minimize the potential virus infection during a surgery. both level-3 ppe and negative pressure operating rooms are suggested for such cases. here we proposed a simple, carton-made, protective shield that provides an effective reduction of transmission of droplets and aerosols during both intubation and extubation. first, we used a carton made of corrugated fiberboard as an alternative to the transparent plastic cube; the design diagrams of the protective shield are now available as an open source at the aerosol block website. 3 then we used a transparent plastic wrap to cover the upper portion of the carton, which allows direct vision inside the shield (figure 1 ). the advantage of corrugated fiberboard is the flexibility to tailor the size of the shield according to the patient's appearance and surgical need. it is also easy to obtain corrugated fiberboard cartons, and the shield is disposable after a single use. before using, to avoid patient anxiety, we recommended communication with the patient describing the protective shield and why it is necessary in the anesthetic evaluation. second, all the intubation devices (video laryngoscope with disposal blade is recommended) should be set inside the shield before induction, including anesthetic circuit and suction tube through the side ports of the shield. after preoxygenation, the laryngoscopist should perform a rapid sequence induction and intubation following covid-19 perioperative management recommendations for the local institution. communicating with the surgeon is also important to ensure that the protective shield will not occupy the operation field. after the a carton-made protective shield for suspicious/confirmed covid-19 intubation and extubation during surgery shield interrupts operation, it should be discarded and a new one prepared for extubation. at the end of general anesthesia, to avoid droplet and aerosol transmission from emergence cough, extubation should be performed inside the shield (figure 2) . finally, the protective shield should be discarded in accordance with contaminated waste. this pragmatic method is definitely not standard airway management of covid-19. however, the protective shield has proven to be effective in minimizing the spread of aerosols during intubation. when extubation of suspicious/confirmed covid-19 after general anesthesia is needed, the adjunct protective shield may help minimize droplet and aerosol transmission and reduce operating room contamination. recommendations for endotracheal intubation of covid-19 patients barrier enclosure during endotracheal intubation key: cord-287553-yev5i6hu authors: babazade, rovnat; khan, ejaz s.; ibrahim, mohamed; simon, michelle; vadhera, rakesh b. title: additional barrier to protect healthcare workers during intubation date: 2020-04-27 journal: anesth analg doi: 10.1213/ane.0000000000004904 sha: doc_id: 287553 cord_uid: yev5i6hu nan to the editor w ith an impending shortage of personal protective equipment (ppe) and rising infection among health care providers, novel coronavirus transmission via aerosolization is promoting new barrier discoveries for provider protection. recently, taiwanese doctors created an "aerosol box" that has 3 openings-2 ports and 1 side, which restrict hand movements and patient positioning; is not feasible to use on emergent situations such as trauma, cardiopulmonary arrest, or a patient requiring emergent cesarean delivery; and has an accessibility with few limitations. 1 although, canelli et al 2 did not identify any leakage out of the aerosol box in their simulation. we describe a novel barrier method made from an easily accessible, cheap, and disposable transparent plastic sheet (120 × 100 cm; figure a) with a crosscut that is marked with a red sticker on the transparent sheet (1.5 × 1.5 cm; figure a) that is positioned at the mouth. in our simulation, the anesthesiologist covered the head of an airway mannequin with this sheet before preoxygenation with a facemask that is connected to the artificial manual breathing unit through crosscut ( figure b ). after induction of anesthesia, vocal cords are visualized either by a direct or video laryngoscope under the sheet ( figure c) , and the endotracheal tube is passed through a marked crosscut in the sheet ( figure d) . after successfully securing the endotracheal tube cuff, the instruments used are isolated to avoid contamination. we proposed to keep the patients head covered during extubation and, if feasible, during surgery. described methods neither restrict hand movement nor require any additional training and still offer additional protection from aerosol spread in the vicinity and to the provider during any lifesaving procedure. proper use of ppe and antiviral filters in close proximity to the patient's airway with negative pressure rooms are strongly recommended for contamination and safety. taiwanese doctor invents device to protect us doctors against coronavirus barrier enclosure during endotracheal intubation funding: supported by the department of anesthesiology, university of texas medical branch at galveston. this article was written by the investigators. the authors have no personal financial interest in this research. a novel barrier method: "aerosol cover." a, disposable transparent plastic sheet (120 × 100 cm) with a crosscut (1.5 × 1.5 cm). red sticker on plastic to identify the crosscut. b, artificial manual breathing unit through a crosscut. c, vocal cords visualization by laryngoscope. d, endotracheal tube is passed through a marked crosscut. key: cord-343904-fjtt3f2e authors: brull, sorin j.; kopman, aaron f. title: clarifications on technologies to optimize care of severe covid-19 patients date: 2020-07-14 journal: anesth analg doi: 10.1213/ane.0000000000005120 sha: doc_id: 343904 cord_uid: fjtt3f2e nan to the editor w e read with great interest the article by dr rubulotta et al 1 and we congratulate the authors for their timely information with regard to strategies and technologies designed to optimize care of patients with severe coronavirus disease (covid-19). however, we would like to point out several issues that may be relevant to those health care workers who are not routinely exposed to the administration of neuromuscular blocking drugs or monitoring of their effects. the section on "monitoring neuromuscular blockade" (section c) 1 needs to be more specific. for instance, while we agree that, "results of train-of-four (tof) should be recorded on the patient's chart on a regular basis," the reader should be guided as to how these results are assessed: are these tof results obtained subjectively (qualitatively), or objectively (quantitatively)? furthermore, what do the authors mean by "tof"? tof stands for "train-of-four" (a pattern of neurostimulation) and assessment of tof can mean either tof ratio (tofr) or tof count (tofc). the 2 terms denote different depths of neuromuscular block that are not interchangeable. 2 we do have significant reservations about the authors' suggestion that the corrugator supercilii muscle should be the monitoring site of choice. it is true that the sensitivity of the facial muscles to nondepolarizing relaxants closely matches that of the diaphragm. however, it is also true that facial nerve stimulation should not be used to guide reversal and recovery. 3 this is because the eye muscles recover earlier than the upper airway muscles and may falsely suggest that sufficient neuromuscular recovery is present even when the adductor pollicis muscle twitch responses may be weak or nonexistent. 3 the authors also fail to give any guidance as to what tofr or tofc the clinician should aim for nor why. the authors recommend a rapid induction-intubation sequence and consider the 1.2 mg/kg rocuronium as the "overall safest combination" when sugammadex is available. the problem with this statement is that the authors argue that if intubation fails, then neuromuscular block can be reversed quickly by administering sugammadex 16 mg/kg. this dose requires opening of six 200-mg vials for a 70-kg patient; this is not an expeditious procedure, particularly in an emergent setting. and, even if prepared in advance, this dose does not guarantee resumption of spontaneous ventilation if the rocuronium administration was accompanied by hypnotic doses of propofol and opioid typically administered on induction of anesthesia. 4 thus, the potential for hypoxia, brain damage, or death remains. the authors also suggest, in the event of an anaphylactic reaction to rocuronium, that sugammadex may abort or reverse this process. while there are case reports that support this observation, considerable controversy exists as to the validity of this treatment. 5 it is also unclear whether "the tof monitoring handheld device" to which the authors refer is a peripheral nerve stimulator or an objective neuromuscular monitor. the 2 devices are not equivalent, and they provide information of vastly different reliability and clinical usefulness. 2 it also has been shown that subjective (tactile) evaluation of the tof count is vastly different based on the muscle assessed: qualitative (subjective) evaluation of tof responses at the eye muscles, for instance, resulted in a >5-fold higher risk of residual paralysis than those patients in whom the hand (adductor pollicis) muscles were assessed subjectively. 6 we therefore believe that clinicians should be very precise in their description of what "monitoring" consists of: is it a subjective (visual or tactile) estimation of responses, or is it based on actual monitoring, which implies measurement and analysis or such responses? despite these relatively minor but clinically important shortcomings, we believe the information is timely and helpful to those on the "front line" in caring for patients with covid-19. technologies to optimize the care of severe covid-19 patients for healthcare providers challenged by limited resources conceptual and technical insights into the basis of neuromuscular monitoring neuromuscular monitoring: more than meets the eye ); has received research funding from merck & co, inc (funds to mayo clinic) and is a consultant for the myth of rescue reversal in "can't intubate, can't ventilate" scenarios sugammadex and rocuronium-induced anaphylaxis intraoperative neuromuscular monitoring site and residual paralysis key: cord-254861-lpzx878m authors: saggese, nicholas p.; rose, adam l.; murtagh, keith; marks, andrew p.; cardo, vito a. title: an interim solution to the decreased availability of respirators against covid-19 date: 2020-04-22 journal: anesth analg doi: 10.1213/ane.0000000000004879 sha: doc_id: 254861 cord_uid: lpzx878m nan to the editor w e read the recent article titled, "utility of substandard facemask options for health care workers during the covid-19 pandemic" by abd-elsayed and karru 1 with great interest. the authors do an excellent job capturing the issue of n95 respirator shortages due to a surge in coronavirus disease 2019 (covid-19) cases and panic use by the public. however, the article emphasizes the importance of facial seal and fit in face masks but they do not provide a solution to this ongoing issue. we would like to shed light on a few more potential alternatives to the n95 that exhibit good facial seal and may be considered under dire circumstances. boston children's hospital has conducted a pilot study on a do-it-yourself reusable respirator. the respirator is comprised of an anesthesia mask, inline ventilator filter, or high-efficiency particulate air (hepa) filter and elastic straps ( figure a) . it has minimal leakage around the mask's edge (if appropriately sized), and breathability was shown to be similar to the n95 respirator but with n100 filtration efficiency (99.97% efficient in filtering viral and bacterial particles). 2 this apparatus can be washed with soap and water or disinfectant when contaminated. the filter should be changed when visibly damaged or difficult to breathe through. 2 our first author applied the mask while simultaneously monitoring pulse oximetry and end-tidal co 2 for 15 minutes. there was no decrease in oxygen saturation, and normal end-tidal co 2 was observed. the mask was comfortable and easy to breathe through. overall, the device was simple to construct and cost-effective. second, the authors mention that surgical masks are "suboptimal, 1 " which is controversial and may not be true. a randomized control study showed that surgical masks offered comparable protection to n95s against viral respiratory infections in the clinical setting. 3 also, a case report from singapore demonstrated 41 health care workers (hcws) who came in contact with covid-19 patients during aerosolizing procedures. the hcws were subsequently tested negative for covid-19. eighty-five percent of the hcws wore surgical masks and 15% wore n95s, showing that surgical masks combined with other recommended precautions were efficacious. 4 however, we do agree that protection in these masks can be optimized with proper seal, as stated by the authors. 1 to better conform a mask to the face, an organization called "fix the mask" designed a "surgical mask brace." all that is needed are 3 rubber bands and a surgical mask. rubber bands are looped together to create a chain. the mask is donned with the middle rubber band over the mask and the lateral rubber bands around the ears to create a better seal ( figure b) . 5 this is also a simple, cost-effective design and is now undergoing quantitative testing by the organization. alternatively, the authors of this letter used 2 tourniquets fashioned together instead of rubber bands to create a better seal ( figure c) . tourniquets are readily available in the hospital system. tourniquets offer an advantage over rubber bands because they are wider, providing more surface area over the edges of the mask. after using this technique and performing a user seal an interim solution to the decreased availability of respirators against covid-19 figure. suggested alternatives to respirator shortages. a, anesthesia mask with inline ventilator filter and head strap. concept adapted from boston children's hospital pilot study. b, rubber band "surgical mask brace" adapted from fix the mask. c, modification of the "surgical mask brace" with tourniquets. www.anesthesia-analgesia.org letters to the editor check, we noticed no evident air leakage around the mask margins during inhalation and exhalation. we would recommend that this be used with an american society for testing and materials (astm) level 3 surgical mask with eye protection and reserved for situations that do not involve aerosol-generating procedures. in conclusion, there is no high-level evidence showing that either of these devices are safe at this time, and none are approved by the national institute for occupational safety and health (niosh) or the food and drug administration (fda). however, these strategies may be good alternatives during crisis capacity. powered air-purifying respiratory hood systems, although expensive, can also be an alternative, especially when performing procedures with high aerosolization. furthermore, it is important to remember that other personal protective equipment (ppe) must be used in addition to the respirator or facemask to protect against severe acute respiratory syndrome coronavirus 2 (sars-cov-2), such as goggles, face shield, gown, and gloves. the user must also correctly don and doff the ppe and hand wash for at least 20 seconds to help prevent the spread of sars-cov-2. solutions to the shortage of n95 respirators are crucial for protecting health care workers from contracting the virus and becoming a vector of transmission to others. utility of substandard face mask options for health care workers during the covid-19 pandemic covid-19: our response to the n95 shortage: making your own reusable elastomeric respirator. boston children's hospital respect investigators. n95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial covid-19 and the risk to health care workers: a case report surgical mask brace: a solution designed by mechanical engineers at fix the mask key: cord-311372-g34gquid authors: zmijewski, jaroslaw w.; pittet, jean-francois title: human leukocyte antigen-dr deficiency and immunosuppression-related end-organ failure in severe acute respiratory syndrome coronavirus 2 infection date: 2020-07-20 journal: anesth analg doi: 10.1213/ane.0000000000005140 sha: doc_id: 311372 cord_uid: g34gquid nan d espite remarkable progress in understanding the immune response to the severe acute respiratory syndrome coronavirus 2 (sars-cov2), optimal management of immune function during severe viral infections remains a major issue among critically ill patients. in this issue of anesthesia & analgesia, a clinical study by spinetti et al 1 revealed serious concerns about the development of immunosuppression among coronavirus disease 2019 (covid19) patients requiring hospitalization in an intensive care unit (icu). a significant number of patients appeared to develop immune dysfunction, as evidenced by reduced amounts of monocytic human leukocyte antigen-dr (mhla-dr). a similar observation has been reported in patients who survive severe sepsis or trauma, but later develop life-threatening immunosuppression. [2] [3] [4] hla-dr is a class ii human leukocyte antigen (hla) expressed on the cell surface of antigen-presenting cells, including monocytes, differentiated macrophages and dendritic cells, as well as b cells. since the first description of role of hla-dr in immunosuppression, 5 hla-dr expression on monocytes has been subsequently proven to be a reliable marker for evaluating immune dysfunction and risk of secondary bacterial infections in sepsis and trauma patients. 3,6-8 thus, reduced amounts of hla-dr can also place covid-19 patients at high risk of secondary and severe bacterial nosocomial infections. this observation is consistent with a clinical report of secondary bacterial infections and end-organ injury among covid-19 patients requiring icu care. 9 a recent examination of hla variations among the world population revealed a significant impact of hlas on the cellular immune response, in particular, on peptides from coronavirus-infected patients. hla-b*15:03 exhibited the greatest capacity to present highly conserved, shared sars-cov2 peptides to immune cells. 10 subsequent studies have recently confirmed that immune dysregulation in covid-19 patients with respiratory failure is associated with a significant downregulation of monocyte hla-dr. 11 an excessive inflammatory response to sars-cov2 has been thought to be the major cause of disease severity and death among patients with covid-19 in the icu setting. 12 in this context, exaggerated neutrophil and macrophage/monocyte proinflammatory activation may trigger development of immune dysfunction, including immune tolerance (defective response to bacterial products, eg, lipopolysaccharide) and reduced host immune capacity against bacterial infections. [13] [14] [15] such inflammatory mechanisms can be relevant in the development of immunosuppression in sepsis survivors, consistent with reduced human leukocyte antigen-dr deficiency and immunosuppression-related end-organ failure in severe acute respiratory syndrome coronavirus 2 infection hla-dr expression on monocytes after an initial activation of immune cells during sepsis syndrome. however, recent studies have indicated that patients with sars-cov2 infection admitted to an icu have significantly lower levels of cytokine production, as compared to sepsis-related ards. 16 therefore, such findings dispute a relevance of "cytokine storm" in covid-19-related development of severe respiratory dysfunction and failure. these findings also indicate that more research is needed to better define the pathophysiology of sars-cov2 and associated immunosuppression. notably, the mechanisms underlying the downregulation of hla-dr in sepsis and trauma are also not well understood. nevertheless, once hla-dr is decreased or deficient, this event upregulates surface expression of the negative co-stimulatory molecules programmed death 1 (pd-1), cytotoxic t-lymphocyte antigen 4 (ctla-4), b-and t-lymphocyte attenuator (btla), and their corresponding ligands, such as pd-1 ligand (pd-l1). these actions can compromise innate and adaptive immune systems, including cluster of differentiation (cd)8-and anergic cd4-positive t cells, and inducing t cell apoptosis. it could be speculated if these are relevant immunosuppressive mechanisms associated with severe sars-cov2 infections (figure) . furthermore, although hla-dr is diminished in monocytes during sepsis and viral infection, many other events can trigger immunosuppression, including t cell senescence, exhaustion, and skewing toward the th17 phenotype. 17 the development of immunosuppression is certainly linked to host's maladaptive response to sars-cov2, likely related to preexisting conditions like aging, diabetes, and cardiovascular complications. 18 immunosuppression elicited in anticancer treatments and graft transplantations are also significant issues leading to infections, including worse outcomes with sars-cov2 infection. several epidemiological studies have shown that aging is disproportionally linked to more cases, increased severity of organ injury, and mortality related to 20 this is a significant issue because aging is characterized by a collective loss of immune responsiveness and paradoxically lowgrade chronic inflammation ("inflammaging"). 21 importantly, although cd14 + cd16 + monocytes significantly increased with age, but they also displayed reduced hla-dr surface expression in the elderly. 22 it is important to note that a reduced abundance of hla-dr is likely not a sole biological event because many hallmarks of aging are coupled with hostcoronavirus interactions in direct and indirect ways, including genomic instability, reduced mitochondrial function, epigenetic alterations, telomere attrition, and impaired autophagy. 19 in particular, mitochondrial dysfunction and metabolic profile of immune and alveolar epithelial cells play a crucial role in bioenergetic maladaptation in response to viral infections. 23 mitochondrial antiviral signaling (mavs) proteins can be released/activated upon viral infection, including sars-cov2. mavs-mediated apoptosis can be suppressed by viral proteins and prevent mitochondrial death or apoptosis to limit virus propagation. 24 on the other hand, leukopenia developed in approximately 70% of hospitalized patients with covid-19, and the mechanism of this cell line death/exhaustion remains to be determined. 25 diabetes and obesity are leading causes of the morbidity and mortality associated with viral infectionrelated cardiovascular complications. type 2 diabetes mellitus (t2dm) is a serious preexisting metabolic syndrome with adverse outcomes in patients with hemagglutinin type 1 and neuraminidase type 1 (influenza strain) (h1n1) influenza and sars-cov2 in icu. [26] [27] [28] [29] diabetes-related hyperglycemia is closely linked to the development of acute ketoacidosis and other metabolic alteration, as well as chronic lowgrade inflammation. 30 a possible impact of t2dm on mortality due to viral infections is the abundance of glucose that favors virus replication. diabetes is also characterized by innate immunity dysfunction, including reduced chemotaxis, phagocytosis, and pathogen killing by monocytes and polymorphonuclear neutrophils. 31 interestingly, it has been suggested that hla regulates immunoreactive inflammation or infection associated with type 2 diabetes. however, the role of hla alleles in pathogenesis of t2dm and t1dm, and subsequent complications are less clear, as both positive and negative associations of dr alleles have been observed. 32, 33 such discrepancies are likely because diabetes mellitus is a multifactorial disease. nevertheless, it would be interesting to determine if a decrease of specific hla-dr alleles contributes to worst outcome in patients with diabetes and critically ill obese patients with covid-19. while interventions available for sepsis and severe trauma are limited to fluid resuscitation and antibiotics, immunomodulatory mechanisms remain the major targets for the development of effective therapies. perhaps, successful completion of a clinical trial for pd-l1 in sepsis could also be tested as a therapy for covid-19-related immunosuppression. given results obtained by spinetti et al, 1 this seems to be a relevant approach to diminishing morbidity and mortality among icu patients with covid-19. another potential benefit is utilization of hla-dr variants as a prognostic tool to identify individuals with a higher risk for severe infection and hospitalization due to covid-19. e reduced monocytic hla-dr expression indicates immunosuppression in critically ill covid-19 patients decreased monocyte human leukocyte antigen-dr expression after severe burn injury: correlation with severity and secondary septic shock assessment of immune organ dysfunction in critical illness: utility of innate immune response markers management of sepsis-induced immunosuppression alterations in function and phenotype of monocytes from patients with septic disease-predictive value and new therapeutic strategies immunosuppression in patients who die of sepsis and multiple organ failure myeloid cells in sepsis-acquired immunodeficiency dynamic monitoring of monocyte hla-dr expression for the diagnosis, prognosis, and prediction of sepsis clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study human leukocyte antigen susceptibility map for severe acute respiratory syndrome coronavirus 2 complex immune dysregulation in covid-19 patients with severe respiratory failure pathological inflammation in patients with covid-19: a key role for monocytes and macrophages advances in the understanding and treatment of sepsis-induced immunosuppression sepsis-induced immune dysfunction: can immune therapies reduce mortality? sepsis induced immunosuppression: implications for secondary infections and complications is a "cytokine storm" relevant to covid-19? marked t cell activation, senescence, exhaustion and skewing towards th17 in patients with covid-19 pneumonia global, regional, and national estimates of the population at increased risk of severe covid-19 due to underlying health conditions in 2020: a modelling study covid-19 and crosstalk with the hallmarks of aging age-dependent effects in the transmission and control of covid-19 epidemics how inflammation blunts innate immunity in aging age-dependent alterations of monocyte subsets and monocyte-related chemokine pathways in healthy adults a sars-cov-2 protein interaction map reveals targets for drug repurposing mavs-mediated apoptosis and its inhibition by viral proteins lymphopenia predicts disease severity of covid-19: a descriptive and predictive study plasma glucose levels and diabetes are independent predictors for mortality and morbidity in patients with sars spectrum of clinical and radiographic findings in patients with diagnosis of h1n1 and correlation with clinical severity covid-19 and diabetes: knowledge in progress clinical epidemiological analyses of overweight/obesity and abnormal liver function contributing to prolonged hospitalization in patients infected with covid-19 diabetes and infection: is there a link?-a minireview immune dysfunction in patients with diabetes mellitus (dm) hla class ii alleles and risk for peripheral neuropathy in type 2 diabetes patients genetic analysis of hla, na and hpa typing in type 2 diabetes and aso key: cord-317602-ftcs7fvq authors: o’reilly-shah, vikas n.; gentry, katherine r.; van cleve, wil; kendale, samir m.; jabaley, craig s.; long, dustin r. title: the covid-19 pandemic highlights shortcomings in us health care informatics infrastructure: a call to action date: 2020-05-12 journal: anesth analg doi: 10.1213/ane.0000000000004945 sha: doc_id: 317602 cord_uid: ftcs7fvq nan s evere acute respiratory syndrome coronavirus-2 (sars-cov-2), the causative agent of coronavirus disease 2019 (covid19) , was designated a pandemic by the world health organization on march 11, 2020 . by that date, hundreds of thousands of people around the globe had been infected, and millions more are expected to suffer physically and economically from the effects of covid-19. scientifically, the pace of progress toward understanding the virus has been dramatic and inspiring: the viral genome was rapidly determined, 1 and a 3.5-angstrom-resolution cryoelectron microscopy structure of the viral spike protein in prefusion conformation was published within weeks of its identification. 2 initial small trials examining the impact of potential therapeutic agents have also been rapidly published; to date, more than 300 clinical trials have been registered, including several for candidate vaccines. 3 in contrast, other aspects of the international covid-19 response have not yet demonstrated similar progress. the need for rapid aggregation of data with respect to the epidemiology, clinical features, morbidity, and treatment of covid-19 has cast in sharp relief the lack of data interoperability both globally and between different hospital systems within the united states. this global scale event demonstrates the critical public health and research value of data availability and analytic capacity. specifically in the united states, although efforts have been made to secure the interoperability of health care data, countervailing forces have undermined these efforts for myriad reasons. in this study, we describe these forces and offer a call to policy action to ensure that health care informatics is positioned to better respond to future crises as they arise. efforts to develop a standard for health care data exchange have a long history, but the most promising arose from the passage of the health information technology for economic and clinical health act of 2009 (hitech). hitech created an economic motivation for the implementation of electronic health records (ehr) across the united states and is, for this purpose at least, widely viewed as successful. by 2017, 93% of small rural hospitals and 80% of office-based physician practices possessed certified health information technology. 4 notably, the staged approach to ehr adoption delayed interoperability requirements until the final stage of adoption. 5 in the competitive us ehr vendor market, this delay led to differences in how vendors approached and implemented interoperability. although it appears that there is general consensus on the use of the substitutable medical apps, reusable technologies on fast healthcare interoperability resources (smart on fhir) standard developed by the nonprofit health level seven international (hl7) for the interchange of data, the standard is not specific enough to ensure, and regulators have failed to require, that different vendors implement the specification in compatible ways. this failure has necessitated the development of health care integration engine software products to bridge the gap, yet another source of financial inefficiency in us health care. 6 furthermore, aspects of the smart on fhir specification remain incomplete. for example, there is no implementation guide for intraoperative anesthesia data, although one may be developed by 2021. 7 it is notable that the hl7 development work in anesthesiology is done entirely by volunteers. the interoperability framework offered by smart on fhir is, by itself, not sufficient for public health and research purposes. smart on fhir is specifically designed for patient-level data sharing. in the absence of regulations that mandate a specific solution, academicians have developed approaches to the organization and dissemination of standards that allow for multicenter data analyses. the observational health data sciences and informatics (ohdsi), a collaborative group of investigators mostly funded by public granting agencies, is presently in the sixth version of its observational medical outcomes partnership (omop) common data model. once an organization transforms its data into the omop model, as many have, it can participate in data analysis with any number of arbitrary partners through a federated mechanism. 8 as with hl7, there is no standard in omop for anesthesiology data, and standards for data from critical care environments remain underdeveloped. within anesthesiology, the multicenter perioperative outcomes group offers arguably the most comprehensive candidate common data model, although costs of participation are high, and most participating sites are academic centers. 9 while the lack of standard specification by regulatory agencies has contributed to these challenges, emr vendors themselves have also played a role. exposing standardized data reduces barriers to adoption of competing ehr platforms, which clearly explains the reticence of vendors to do so. this year, the chief executive officer of a dominant us ehr vendor wrote a letter in which it urged its customers to oppose proposed regulations that would simplify the sharing of patient data; perhaps unsurprisingly, vendors with less market share and other companies attempting to enter the space voiced support for those same regulations. [10] [11] [12] amidst the covid-19 crisis, further delays in regulatory implementation are under consideration at the very time that data sharing is urgently needed. 13 it is worthwhile to note that the widespread penetration of ehrs into hospital systems facilitated by the hitech act did allow individual systems to react and adapt to the covid-19 pandemic in intelligent, data-driven ways. as an example, uw medicine-one of the first health care systems in the united states to encounter the disease-developed a comprehensive set of information technology solutions in response to the pandemic, including order sets, documentation templates, and dashboards. 14 the value of the ability to rapidly collate and present information at the institutional level should not be underestimated, even as the potential benefits of interinstitutional data sharing during a pandemic remain as yet unrealized. the framework of proportionality is helpful for considering the ethical ramifications of broad data sharing, especially as seen through the lens of a pandemic. it is critical to balance the probable public health benefits of an intervention with the potential infringements on patient privacy or autonomy. 15 the many benefits of real-time data sharing in the context of a global health care emergency have already been outlined. to briefly recap, if hospitals across the country were able to observe and interpret data being gathered at other institutions in real time and to contribute their own data to the shared repository, the health care system could be learning about and improving its care of covid-19 patients continuously and collaboratively, based on the sum total of available information rather than incrementally in silos. even as biomedical publishing gradually evolves to become more agile and rapid, traditional approaches to medical knowledge creation and dissemination remain unacceptably slow and continue to permit the dissemination of inaccurate information in the midst of a pandemic. indeed, calls have been made to address the ongoing "infodemic" (as it has been dubbed by the world health organization). 16 additionally, the sharing of data across health systems would hold hospitals accountable for providing care that is consistent with agreed-upon ethical principles during public health crises, such as allocating treatments in ways that maximize the number of lives saved and treating patients equitably with regard to race, ethnicity, and insurance status. who would monitor and report back on such issues? the us centers for disease control national healthcare safety network (nhsn), established to gather data on (primarily bacterial) health care-associated infections, provides a model for centralized aggregation and reporting but would require heavy revision for our purposes. because the system relies on manual case review and entry, data captured are delayed and results are aggregated on a quarterly basis, too slow and too error prone in the context of a rapidly evolving pandemic. 17 the centralized approach also introduces concerns related to oversight and performance penalties, as well as barriers to use by academic researchers. unlike the nshn, such a system would need to automate aggregation to real-time or near realtime status, provide mechanisms to allow research use of data, provide systems for deidentification of data and protections against reidentification of patients, and potentially be firewalled from traditional quality and pay-for-performance reporting purposes to maximize public health surveillance and research capabilities. potential harms that must be considered include breaches of patient privacy, premature decisionmaking based on preliminary or inaccurate information, and the potential misuse or misinterpretation of shared data. privacy concerns have been raised by ehr companies and health care providers as a major reason not to enter into data-sharing agreements. while it is true that the risk of data breaches might increase with increased interoperability, they need not necessarily become more probable. effectively implementing safeguards around encryption, authentication, and data use can mitigate these risks (the risk of ehr data exposure is not, eg, uniquely greater than financial data compromise), which must be balanced against the potential benefits to patients and public health. there are few remaining legal barriers to the sharing of health information. 18 however, legal, ethical, and logistical challenges arise when a health care system houses data that are not necessarily from that system's patients. large institutions may serve as reference laboratories for broad geographic areas and therefore house assay data from external clients that may or may not have agreed to this type of data sharing. indeed, without careful handling, inclusion of outside clients' results, when combined with data from other regional systems, may lead to unrecognized data duplication. institutions must also consider how they will manage and protect the data generated from testing their own employees in the context of a pandemic. apart from legal restrictions on handling of employee health information that stand apart from health insurance portability and accountability act (hipaa) restrictions, there are ethical challenges in understanding how these data might best be used to study the risks to health care workers while also respecting health care worker privacy. on balance, the ethical obligation, then, is for the companies facilitating data sharing and/or storage to ensure their systems meet the highest standards for security. by contrast, risks to privacy may actually be increased as long as ehr systems are not interoperable, given that patient data may be scattered across multiple systems. other risks that may accompany the sharing of real-time clinical data should be acknowledged. for example, the information itself may be inaccurate due to charting errors or coding inconsistencies. decisionmakers may jump to premature or biased conclusions based on apparent associations between an infectious disease and groups that have been the object of adverse implicit or explicit association bias (eg, racial and ethnic groups, homeless, prisoners, sex workers), leading to further stigmatization and limited access to care. such risks might be increased in the setting of a global crisis characterized by a rapidly spreading virus, widespread fear, and unreliable media sources. on balance, however, our view is that there are no public health benefits to the status quo. proprietary control over ehr data benefits only ehr vendors themselves-who profit from institutional contracts and inhibitors to marketplace competition-and their customers-who may retain patients by virtue of limited or absent interoperability. the harms of the status quo include increased health care costs, such as duplicate testing when records are not transferable. the failure to implement interoperable health care records may also harm patients by trapping their data in balkanized systems, keeping physicians from accessing needed information in an efficient manner. access to prior documentation of critical conditions (eg, a difficult airway or history of malignant hyperthermia or critical aortic stenosis) would allow anesthesiologists to make safer, more efficient diagnostic and care decisions. frontline providers shouldering the burdens of health care under pandemic conditions are rapidly realizing that competent physicians and other health care workers can only go so far to solve problems that arise from systemic dysfunction. lack of data infrastructure inhibits communication and study of rapidly evolving clinical practice. hospitals within blocks of each other are relying on ad-hoc interpersonal communications rather than working from a coherent multiorganizational playbook. the seamless capability to share ideas, care plans, and experiences based on reliable data would dramatically alter the us health care landscape. on a smaller scale, interoperability challenges also exist within hospital systems or single hospitals themselves. lack of data interoperability at the device level has ensured that hospital systems have to navigate and manage streams of data from diverse legacy devices, creating challenging data acquisition issues in the context of a surging number of covid-19 cases. www.anesthesia-analgesia.org anesthesia & analgesia covid-19 and data infrastructure shortcomings when confronted with a novel disease process, small and often poorly conducted studies rapidly proliferate. these studies are disseminated in mass and social media and may drive therapeutic decisions that could be ineffective at best and cause substantial harm at worst. in the context of covid-19, a context where millions have contracted the disease and hundreds of thousands will likely die, timely but robust science is needed. the ability to share and combine data across systems serves as the foundation of such efforts. with data standardization and sharing, variability in care approaches could be harnessed to identify best practices and therapeutic avenues in a much more cohesive, data-driven manner. several concrete examples are illustrative. infection control procedures and equipment or medication shortages related to covid-19 are significantly impacting the timing of surgery, default approach to airway management, maintenance of anesthesia, and the setting in which postoperative monitoring occurs. such rapidly developed policies are intended to protect anesthesia providers and other health care workers and to conserve critical resources, but is there a signal for patient harm associated with such sudden and profound changes in practice? additionally, anesthesia departments are increasingly relying on the results of preoperative sars-cov-2 testing to guide such policies. the efficacy of these screening systems (particularly when applied to asymptomatic patients or those in whom such a determination is not possible) is unknown but is of critical importance for airway management, for determining personal protective equipment requirements during anesthetic care, and for determining safe postoperative disposition. collectively, surgical patients undergoing preoperative evaluation are poised to become the largest cohort of asymptomatic patients tested for sars-cov-2, and yet the power of this potential resource to broadly inform health care policy will likely go unutilized. unexpected but fundamentally important aspects of this emerging disease, such as the large number of patients presenting for endovascular therapy for acute ischemic stroke, may be uncovered through coordinated approaches to discovery. 19 finally, there has been a rapid shift toward the use of anesthesia machines to meet surge demands for mechanical ventilation. reasonable evidence exists to suggest that modern anesthesia machines are virtually indistinguishable from intensive care unit (icu) ventilators; however, icu ventilators are more fault tolerant, handle circuit leaks more optimally, and handle fresh gas in very different ways. anesthesia machines set improperly and operated by health care providers unfamiliar with their use may unnecessarily waste medical gases or (in the worst case) deliver hypoxic gas mixtures in the context of inadequate oxygen flow into the circle system. again, the impact of such a rapid retasking of medical equipment will, under the current infrastructure, remain unknown for much longer than should be necessary. the public has a pressing interest in ensuring that data standards (eg, omop, fhir) are rapidly developed, adopted by appropriate international standards organizations (eg, hl7), and implemented by ehr vendors in a manner that facilitates interoperability for individual patient care, public health, and research purposes. 20 we agree with others that this will require changes to the regulatory environment created by the hipaa. 21 anesthesiologists, along with nurses, respiratory therapists, advanced practice providers, emergency room physicians, intensivists, and other critical care professionals, stand at the front line of the covid-19 public health crisis. better data are required to delineate every aspect of this pandemic: supporting local operations and quality work; informing research queries, such as investigations into provider risk following airway management and quantifying the efficacy of therapeutic options; and bolstering public health efforts by providing real-time prevalence, tracking disease spread, and facilitating risk stratification. integration of health care data with nonhealthcare source data is currently an impossibility in the united states due to lack of a universal health care identifier. 22 public funding agencies and their grantees have shouldered the burden of creating stopgap solutions that policymakers have failed to require and major ehr vendors have avoided due to risk of competitive disadvantage. policymakers and funders are called upon to prioritize the modernization of health informatics. anesthesiologists and our specialty societies are called upon to advocate policymakers for these changes and to involve themselves in these organizations in the coming months and years and contribute to development or otherwise risk failing again in optimizing a data-driven response to the next pandemic. e a new coronavirus associated with human respiratory disease in china cryo-em structure of the 2019-ncov spike in the prefusion conformation search of: covid-19 -list results -clinicaltrials the office of the national coordinator for health information technology. health it quick stats g2. best healthcare integration engines software in 2020. available at hl7 international. anesthesia -documents. available at epic's ceo is urging hospital customers to oppose rules that would make it easier to share medical info cerner growing ehr market share with increased hospital consolidation: klas. fiercehealthcare cerner call for interoperability rule release hhs considers rolling back interoperability timeline amid covid-19. healthcare dive responding to covid-19: the uw medicine information technology services experience teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes pseudoscience and covid-19 -we've had enough already truth in reporting: how data capture methods obfuscate actual surgical site infection rates within a health care network system legal barriers to the growth of health information exchange-boulders or pebbles? anesthetic management of endovascular treatment of acute ischemic stroke during covid-19 pandemic: consensus statement from society for neuroscience in anesthesiology & critical care (snacc)_endorsed by society of vascular & interventional neurology (svin) perioperative documentation and data standards--anesthesiology owned and operated balancing health privacy, health information exchange and research in the context of the covid-19 pandemic the us lacks health information technologies to stop covid-19 epidemic the authors declare no conflicts of interest.reprints will not be available from the authors. key: cord-324388-onc441uw authors: siddiqui, urooj; hawryluck, laura; muneeb ahmed, muhammad; brull, richard title: same-day consent for regional anesthesia clinical research trials: it’s about time date: 2020-08-12 journal: anesth analg doi: 10.1213/ane.0000000000005196 sha: doc_id: 324388 cord_uid: onc441uw nan c oronavirus disease 2019 (covid-19) has changed the way anesthesiologists engage and interact with patients. as we hopefully approach the backend of this crisis, plans for the resumption of "nonessential" anesthesia services, including providing anesthesia for elective surgeries, reopening of anesthesia preoperative assessment clinics (pac), and recruiting for regional anesthesia clinical research trials, will take shape. the covid-19 pandemic has, however, highlighted a significant challenge in the current approach to research and the advancement of scientific knowledge in the regional anesthesia field: the perceived need to obtain consent to participate in such research in advance of the actual day of surgery. notwithstanding the low-risk nature of participation in most regional anesthesia clinical trials, subject recruitment on the same day as surgery is often prohibited by local research ethics boards (reb) due to their concerns regarding patient autonomy and perceptions of patient vulnerability immediately before surgery that could impact the voluntary nature and the rigor of the informed consent process. in many centers, the anesthesia pac has long served as the sole permissible and fertile ground for subject recruitment to clinical research, presumably ensuring fully informed consent to participate in a clinical trial in the absence of any undue duress and facilitating the establishment of a mutually trustful relationship. with the covid-19-related suspension of in-person assessments in anesthesia pacs across most academic centers, recruitment for ongoing regional anesthesia clinical research trials has come to an abrupt halt and brought the long-standing controversy of same-day informed consent for low-risk clinical trials squarely back to the fore. the widespread reb concerns regarding same-day informed consent for participation in regional anesthesia research trials have not been supported in the current literature. even though anxiety in the face of impending surgery is a normal human reaction, patients are still presumed to be capable to continue to consent or to revoke consent to surgery while they wait to enter the operating room. there is no evidence that carefully conducted assessments of capacity to understand information pertaining to a research study and to appreciate how a choice to participate or not would apply to them cannot be performed in this period. there is no existing literature to suggest that patients are so vulnerable during this period that they must be systematically protected by prohibiting any discussion of potential participation in research in the immediate preoperative period. arguably, such a systematic prohibition is ethically problematic in that, on its face, it appears paternalistic and can deny patients the benefits of research participation. the anticipation of a second wave of covid-19 and the high likelihood of future pandemics from other emerging pathogens requires a more rigorous examination of such reb assumptions as prohibiting same-day consent to participate in regional anesthesia research risks stymying research and growth of this important and innovative field and fail in its goal to benefit patients in the perioperative period. the 1964 declaration of helsinki outlined the tenets of informed consent: competency, disclosure, autonomy. 1 to ensure autonomy, subjects must offer their participation voluntarily, specifically, without any element of force, fraud, deceit, duress, or coercion. these tenets remain the pillars on which clinical research involving humans is founded and inform the respective canadian and american anesthesiologists' society's guidelines for the ethical consult of clinical research. 2,3 despite adaptations and updates over several decades, a single truth has prevailed: consent is paramount and, as with treatment, no research can occur without consent. chief among the roles of rebs is to ensure the consent process is rigorous and the autonomy of clinical research participants is respected. while the meaning of consent is both uniform and clear, that is, research participants must be capable of decision-making, fully informed, with ample time for consideration of options without coercion, and their choice must be respected, 1 what constitutes ample time is not as clearly defined. the world health organization states that "subjects must be given ample opportunity to enquire about the details of the trial… sufficient time, determined by the patient's health condition." 4 the tri-council policy statement, representing canadian standards for ethical research involving humans, declares that "for consent to be informed, prospective participants shall be given adequate time and opportunity to assimilate the information provided." 5 in the united states, the american medical association is even less explicit, stating only that a valid consent process includes, "reviewing the process and any materials to ensure that it is understandable to the study population." 6 locally, the university of toronto's position on "ample time" is equally vague, only to consider "whether the contact person is known to the subject/ authorized third party, has access to the patient information as part of their normal professional duties, or is able to assess capacity to consent." 7 while there is currently no uniform explicit recommendation or absolute quantification for what constitutes adequate time for patient reflection before consenting to participate in a clinical research trial, 4, 5, 7 hospital-based rebs are also given some guidance regarding how much time is inadequate. specifically, the canadian national council on bioethics in human research likens the practice of same-day consent to intimidation, coercion, and breach of autonomy. 8 ostensibly equating quantity with quality, some rebs have strongly discouraged same-day consent practices, instead opting for a minimum of 1-2 weeks for patient contemplation, irrespective of risk involved in study participation. outside of north america, guidelines and recommendations on consenting practices for clinical research trials are similarly varied. the table summarizes available recommendations from various international professional societies and government agencies regarding consent practices in the context of clinical research. recommendations range from the oft-repeated requirement for "adequate" or "sufficient" time 9,10,13 to a more explicit demand for at least 24 hours for patient consideration. 11 a notable deviation is the proportionate approach to seeking consent for clinical trials advised by united kingdom's national health service (nhs). 14 when seeking consent for patient participation in a clinical trial, the nhs recommends that "for research involving only minimal risks and/or little deviation from normal/standard clinical practice… it may be reasonable to accept a decision taken at the time of approach." 14 additionally, the extent of information provided ought to be proportionate to the "nature and complexity of the research trial, risks, burdens, and potential benefits, the ethical issues at stake." 14 most physicians and surgeons meet with their patients on multiple occasions, affording these investigators time to identify, recruit, and enroll suitable research participants and obtain informed consent. however, specialties, such as anesthesiology, critical care, interventional radiology, and emergency medicine, have a varied pattern of practice and patient acquaintance that does not typically afford the luxury of time or, in many cases, delayed consent to research. 15 indeed, the initial encounter between anesthesiologists and patients undergoing elective procedures routinely occurs on the day of surgery. recognizing our specialty's unique practice patterns, the canadian anesthesiologists' society's guidelines on the ethics of clinical research state that "preoperative consent for clinical research in anesthesia may be obtained after admission to hospital, either before or on the day of the scheduled surgery." 2 yet an impasse is occurring in regional anesthesia with clinical investigators working in a time-limited perioperative system yet prohibited by rebs, both locally and otherwise, from consenting patients for clinical trials on the same day as surgery. 8, 15 the question of patient vulnerability and need for protection in practice concerns of inadequate patient comprehension, time for contemplation, and privacy, as well as undue duress, coercion, and anxiety, continue to undermine same-day consent for regional anesthesia clinical research trials. these concerns, however, have not been borne out in the literature. when consent is obtained on the same day as surgery, the vast majority of patients do understand the intent of the clinical anesthesia trials and recognize that participation is voluntary and that consent may be withdrawn at any time without consequence. 16, 17 patients are capable of digesting consent form documents and making informed decisions about research participation in thirty minutes or less. 16, 18 similarly, most patients feel that the perioperative setting offers adequate privacy for consent discussions. 16 purported coercion of patients by their clinician investigators in the immediate preoperative setting has also been refuted 16, 17 ; 1 anesthesia study found that 97% of patients rated the preoperative setting as "ideal" for obtaining informed consent to participate in clinical anesthesia trials. 16 "it is good practice where possible to seek the service user's consent to the proposed procedure well in advance, when there is time to respond to the service user's questions and provide adequate information." "where the research entails only minimal risk, it is sufficient if the research offers the prospect of benefits either to the participants directly or to the group which is the focus of the research and to which the participants belong." "asking a service user to provide consent just before the procedure is due to start, at a time when they may be feeling particularly vulnerable, or seeking consent from someone who is sedated, in pain or anxious, creates doubt as to the validity of the consent." "where the research poses more than minimal risk, it should … offer the prospect of direct benefits for the participants themselves and be commensurate with the level of foreseeable risk." new zealand auckland district health board (2018) 13 "sufficient time should be allowed for the patient to read the written information, and discuss this and any verbal information with whomever they wish." "the higher the probability of risk or the greater the magnitude of harm, the more care and detail in giving information is required." "the patient must be informed of rare risks that are more likely because of their particular circumstances, or which would have greater significance for that particular patient, for example, the consequences of arm nerve damage for a carpenter." united kingdom nhs health research authority (2019) 14 "there are no definitive guidelines or legislation regarding the appropriate amount of time (or minimum amount of time) that potential participants should be allowed to consider whether to take part in research or not. a proportionate approach (in a nonurgent scenario) means that for more complex or burdensome studies a longer time may need to be provided for potential participants to consider their decision than that provided for simpler studies involving lower risks…for research involving only minimal risks…it may be reasonable to accept a decision taken at the time of approach." "a proportionate approach to seeking consent, that is, adopting procedures commensurate with the balance of risk and benefits, should always be adopted so that potential participants are not overwhelmed by unnecessarily lengthy, complex, and inaccessible information sheets but instead are provided with succinct, relevant, truthful information in a user-friendly manner that better promotes their autonomy." "the methods and procedures used to seek informed consent and the level of information provided should be proportionate to: -nature and complexity of the research -risks, burdens, and potential benefits -ethical issues at stake" abbreviation: nhs, national health service. www.anesthesia-analgesia.org same-day consent for regional anesthesia research the latter is most likely explained by patient preference for physicians with whom they will and/or must establish a relationship; accordingly, same-day consent by the responsible physician is likely superior to that by any surrogate. 18 moreover, concerns of patient anxiety have not been realized as anesthesia researchers found no incremental increase in patient anxiety with same-day versus day-before recruitment and consent. 19 finally, increasing the quantity of time for patient contemplation as a means to increase the quality of the informed consent process for regional anesthesia research has not been substantiated. 20 moreover, nowhere in medicine is the direct relationship between vulnerability, quantity of time for patient contemplation, and quality of consent more poignantly questionable than in the intensive care unit (icu). rarely are patients (and their substitute decision-makers) more vulnerable than when a person is admitted to an icu with life-threatening illnesses. nonetheless and until proven otherwise, icu patients (or their substitutes) are deemed capable of making life-altering, and sometimes life-ending, and participation in research decisions in one or more moments of time. 21 furthermore, similar to academic regional anesthesiologists, emergency medicine and radiology clinician investigators have limited interaction with their potential study participants, often meeting on a single encounter with no opportunity to recruit and consent their patients in advance of that encounter. recognizing these limitations, rebs allow for deferred, targeted, or staged consent in order for patients to participate in emergency medicine clinical trials. 22 while such urgent or emergent adaptations to the standard informed consent process are not justified for the elective perioperative setting wherein most regional anesthesia clinical trials occur, the same is not true for the radiology research experience. indeed, low-risk radiology studies are generally approved for enrollment, recruitment, and consent on the same day as the radiological investigation or intervention. 23 the radiology ("x-ray") department may be unlike the operating room environment with respect to heightened patient anxiety; nonetheless, parallels are readily drawn between these 2 settings, including limited time and privacy, the potential for coercion, as well as the low-risk nature of many radiology and regional anesthesia clinical trials. one workaround to ensure a robust consent process and patient protection, adopted by many anesthesia research programs, including those at the university of toronto, has been the anesthesia pac. principally purposed to mitigate or optimize patient-related factors that may increase risk of perioperative complications, anesthesia pacs also function as the sole permissible venue (by our local rebs) for subject recruitment by research staff to low-risk clinical anesthesia research trials wherein subjects can provide informed consent days to weeks ahead of surgery. unfortunately, however, this long-standing workaround is fraught with challenges in appropriate recruitment of participants in that patients attending pacs are likely to be sicker and thus ineligible for study inclusion than those fitter patients who do not attend pac 15 and are more likely eligible for regional anesthesia clinical research. while the idea of coordinating with surgical colleagues to have healthy patients referred to pac for the secondary purpose of study recruitment may be convenient for investigators, when balanced against creating inconvenience and lost income for patients, the use of hospital resources, health care dollars, and pac time constraints, the idea quickly loses appeal. 16 another makeshift solution is preadmission telephone calls, which have been used to introduce research protocols and initiate the informed consent process. however, many institutions consider these calls a violation of patient privacy as research personnel callers are not yet within the patient's circle of care. 15 furthermore, scheduling of calls, anxiety provoked from unsolicited calls originating from the hospital, and constraints in time and manpower represent important ethical and logistical challenges. 18, 24 conceivably, the covid-19 pandemic may alter patient and provider views on telephone or videoconference as means to identify, recruit, enroll, and consent for research protocols. though the pandemic has already rendered telemedicine more applicable and acceptable to patients and practitioners alike, whether or not it could or should penetrate clinical research programs to a similar degree, especially with respect to preserving the sanctity of privacy within the circle of care, will require ongoing consideration. 18, 25 ongoing requirements for universal masking inside of hospitals may further complicate recruitment and consent for clinical trials as clinician investigators must first establish a trustful relationship with potential research participants. while it removes the physical face-to-face component of a patient-physician interaction, 1 potential advantage of telemedicine is that it does allow unencumbered facial recognition and mutual awareness of affect. thus, the persisting effects of telemedicine on clinical research programs beyond this pandemic are yet to be seen and require further study, including the patients' understanding and appreciation of disclosed information, perceptions of the consent process, concepts of ample time for decision-making, patient perceptions of coercion, and ability to make decisionmaking voluntarily and research recruitment rates. yet, our current understanding of patients' ability to provide same-day consent, 16, 17 the lack of evidence of perceived or actual coercion, the perceived value of the fiduciary relationship with the physician performing the procedure, [16] [17] [18] and its low-risk nature would seem to mandate a reconsideration of the absolute prohibition on obtaining same-day consent for regional anesthesia clinical research instead of seeking to create more workaround solutions which may be more disruptive to patients and generate more patient anxiety. most regional anesthesia clinical research trials primarily strive to improve and prolong pain control in the acute and subacute postoperative settings. in comparing the risk-benefit ratio for typical regional anesthesia clinical research trials versus that of other anesthesia subspecialties, it is evident that a proportionate approach to consent protocols is warranted. 14 prohibiting same-day consent practices threatens systematic exclusion of patients otherwise fit and competent who may benefit from participation in regional anesthesia clinical research trials. ostensibly, the issue of same-day consent and its implications for clinical research trials would apply to all fields of anesthesia, but this is not necessarily true. regional anesthesia is unique from other anesthesia subspecialties in its predilection for healthy and fit patients undergoing elective surgical procedures commonly in an ambulatory setting. in contrast, clinical trials in other anesthesia subspecialties (such as cardiac, thoracic, transplant, trauma, and obstetrical anesthesia) typically involve study of riskier interventions or care modifications with generally less resilient patients. we recognize that consenting practices for regional anesthesia research trials vary across north american institutions, and consent on the same day as surgery is permissible at some institutions that house leading regional anesthesia research programs. however, our governing institution-the university of torontopublishes the second most scholarly journal articles in our specialty, second only to harvard university, 26 yet the esteemed research hospitals affiliated with both the university of toronto and harvard university do not allow same-day consent for recruitment of patients to clinical anesthesia research trials. such prohibitive regulations regarding same-day consent must not be the model for other institutions striving to develop their own regional anesthesia clinical research portfolios. it behooves all regional anesthesia investigators to learn from the covid-19 pandemic and identify opportunities for growth thereafter. the covid-19 pandemic has unceremoniously exposed the arranged and strained marriage between our heretofore proliferative clinical regional anesthesia research program and our anesthesia pacs. during an unprecedented time in which clinical research and knowledge are driving day-to-day political, economic and health care decisions with monumental impacts locally, nationally, and globally, regional anesthesia research has been brought to a halt. while the issue of consent is not one to be taken lightly, the validity of same-day consent for low-risk anesthesia research trials has been widely supported. 8, [15] [16] [17] [18] [19] indeed, the nhs has responsibly acknowledged that the timing of consent can vary depending on the risk of study participation and that a universal "one-size-fits-all" approach to the timing of consent is not reasonable. 27 it is the process, rather than the time, that is the central to the validity of informed consent and safeguarding subject autonomy. 8 prohibiting same-day consent for low-risk regional anesthesia clinical trials is an overly burdensome exercise for both clinical investigators and research staff. and so, while we continue to practice physical distancing, it is, in our opinion, high time to distance ourselves from such a prohibitive practice. world medical association declaration of helsinki: ethical principles for medical research involving human subjects guidelines on the ethics of clinical research in anesthesia guidelines for the ethical practice of anesthesiology who guidelines for good clinical practice (gcp) for trials on pharmaceutical products: responsibilities of the investigator tri-council policy statement: ethical conduct for research involving humans www.anesthesia-analgesia.org anesthesia & analgesia same-day consent for regional anesthesia research 7. toronto academic health sciences network (tahsn). guidelines for research ethics review involving human subjects same day consent for anaesthesia research the national health and medical research council, the australian research council and universities australia clinical trials regulation: informed consent and information to patients. european patients forum guidelines about notification etc auckland district health board applying a proportionate approach to the process of seeking consent. nhs health research authority informed consent for clinical anaesthesia research consent for anesthesia clinical trials on the day of surgery: patient attitudes and perceptions are patients comfortable consenting to clinical anesthesia research trials on the day of surgery? surgical patients' attitudes regarding participation in clinical anesthesia research protocol understanding and anxiety in perioperative clinical trial patients approached for consent on the day of surgery say what? patients have poor immediate memory of major risks of interscalene block disclosed during the informed consent discussion issues of vulnerability and equality: the emerging need for court evaluations of physicians' fiduciary duties in high stakes end-of-life decisions targeted consent for research on standard of care interventions in the emergency setting an overview of informed consent for radiologists a preadmission telephone call to initiate the consent process for clinical anesthesia research perspective on covid-19: finally, telemedicine at center stage trend of academic publication activity in anesthesiology: a 2-decade bibliographic perspective balancing the quality of consent key: cord-310104-1c7q9m06 authors: sasangohar, farzan; jones, stephen l.; masud, faisal n.; vahidy, farhaan s.; kash, bita a. title: provider burnout and fatigue during the covid-19 pandemic: lessons learned from a high-volume intensive care unit date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004866 sha: doc_id: 310104 cord_uid: 1c7q9m06 nan t he novel coronavirus disease 2019 (covid19) pandemic has resulted in an overall surge in new cases of depression and anxiety and an exacerbation of existing mental health issues, with a particular emotional and physical toll on health care workers. 1 limited resources, longer shifts, disruptions to sleep and to work-life balance, and occupational hazards associated with exposure to covid-19 have contributed to physical and mental fatigue, stress and anxiety, and burnout. 2 similar to most hospitals in the covid-19-affected areas, the houston methodist hospital (hmh) system has experienced an overwhelming impact of this pandemic on personnel. for example, we have observed an unprecedented number of staff requesting americans with disabilities act exemptions. physicians and nurses are worried about their families, and some hesitate to go home in fear of exposing family members to infection. it is common to see emotional exhaustion in the intensive care unit (icu). we have observed front-line health care providers emotionally breaking down, mainly due to the added pressure to choose between family responsibilities and their inner sense of duty toward patients. at the same time, we have seen an overwhelming influx of support from medical leadership, public and private acknowledgments, community support (eg, food sent to care units), as well as additional services offered to staff, such as music therapy, counseling services, chaplain services, and accommodations in work schedules. other organizational adaptations include allocation of more resources (eg, float nurses, physicians, patient care assistants, and new equipment). moving forward, our institution has plans for marshaling resources from surgeons, anesthesiologists, other medical specialists across all disciplines, and, in extreme circumstances, anyone with medical training and background. in this article, we share the lessons learned collectively by an interdisciplinary team of icu leadership and collaborating scientists at the center for outcomes research at hmh about the experience of occupational fatigue and burnout of intensive care personnel as a result of responding to the covid-19 pandemic. we propose specific policy recommendations and guidelines for organizational readiness, resilience, and disaster mitigation. of urban, suburban, and rural settings. for more than 100 years, hmh has served the houston and global community with the highest quality patient care in a spiritual environment-indeed ironically, beginning its existence amidst the 1918 influenza pandemic. hmh has 952 operating beds (2393 systemwide) and 8294 employees (25,543 systemwide) . each year, it has 45,511 emergency room visits, 381,585 outpatient visits, and 41,976 admissions (more than 1.3 million outpatient visits and more than 126,000 admissions systemwide). 3 us news & world report has named hmh the no. 1 hospital in texas for 8 consecutive years, with placement among its top 20 "best hospitals honor roll" 3 times. in addition, hmh is nationally ranked in 9 specialties, 4 and has been named the no. 1 employer in texas by forbes. 5 of particular note regarding its critical care capacities during this pandemic, hmh has 5 icu units (cardiovascular, medical, coronary, surgical, and neonatal-with a total of 130 icu beds), with 311 icu beds systemwide across the community hospitals. at the time of this writing, hmh is caring for about 120 patients who have tested positive for covid-19. the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is in the same family as the causative agent for previous middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) outbreaks. covid-19 arose most likely from animal-to-human transfer in wuhan, china. unlike previous coronavirus outbreaks, the current covid-19 emergence was marked by high rates of person-to-person transmission, including from asymptomatic carriers, combined with high severity of illness in vulnerable populations, including those with very common preexisting chronic conditions like diabetes, heart disease, and lung disease. 6 the dilemma posed to health care workers is 2fold: first, the anticipated, and now experienced, overload on the health care system capacity to respond to this pandemic with a suitable flow of equipment; and second, the high risk posed to health care workers on the front lines and their family members as a result of constant exposure. the public has been repeatedly called on to "flatten the curve," in reference to the social and behavioral changes that we as a society can undertake to slow the spread of disease. this strategy has been prominent in us centers for disease control and prevention (cdc) reports since 2007, with maintenance of the guidelines as recent as 2017. 7, 8 this strategy was even deftly memed by medical experts on social media. 9 however, across several states, implementation of these preventive measures has fallen short of desired goals. 1,2,10-14 several factors may have exacerbated occupational fatigue and burnout in icus. given our overarching roles across various facets of the health care system and our first-hand experiences with the response, the "lessons learned" documented here provide a holistic overview of major system-level problems exposed by the pandemic. in what follows, 4 major contributors to covid-19-related occupational fatigue and burnout are discussed: (1) occupational hazards; (2) national versus locally scaled response; (3) process inefficiencies; and (4) financial instability. given the highly contagious nature of sars-cov-2, the us cdc has published strict infection control and prevention guidelines for front-line health care workers, including limited administrative access, strict workplace hygiene requirements, and usage of personal protective equipment (ppe). 15 the rapid spread of the covid-19 pandemic revealed an overall lack of preparedness and insufficient training as well as limited supplies of ppe for icu staff, including anesthesiologists, intensivists, pulmonologists, nurses, respiratory therapists, and other front-line providers in most affected areas. from the onset of the covid-19 outbreak, it was apparent that testing for the virus, detecting its distribution through widespread surveillance, and subsequent contact tracing were major public health gaps. most hospitals, including hmh, lacked the capacity to test significant portions of our patient population for novel infectious threats. this removed a highly effective infection control tool from our arsenal. unfortunately, such unpreparedness, potentially resulting in poor patient outcomes, had a significant psychological burden on personnel. the covid-19 outbreak also exposed the inadequacy of the us strategic national stockpile (sns) of ppe and ventilators during a pandemic affecting many states. in fact, to our knowledge, only 10%-25% of states' requested ppe is being delivered, about 1 month into the pandemic. in addition, there are many uncertainties about when and how more ppe-and most important, ventilators-will become available. the process to access the us sns should be as lean as possible, but it has proven slow and logistically cumbersome. while federal authorities are assembling practical guidelines to extend the life and use of ppe, such plans may void the warranty on ppe. 16 critical care personnel are well aware that the effectiveness of ppe deteriorates outside of recommended usage, and such awareness only worsens the psychological pressure on these personnel. the covid-19 pandemic has revealed several issues related to current processes and established practices. most importantly, the lack of established policies for pandemic triage, equipment ordering, and emergency management has led to systemwide inefficiencies and has increased the burden on health care workers. while new protocols were put in place in response to the pandemic, these protocols were perceived as complex and, in some cases, premature. for example, anecdotal evidence suggests that most health care workers' vulnerabilities and contamination were related to improper ppe doffing. while training videos on donning and doffing were shared with staff, such videos were not updated to reflect specific ppe used in our system, and instructions were not intuitive for less experienced personnel. another important issue was related to policy overload coupled with mismatching policy from different levels or sources. for example, each subspecialty (eg, anesthesiology, critical care medicine, respiratory therapy, nursing, and others) follow guidelines provided by their respective professional societies for various procedures, in addition to new policies developed by the hospital. however, holistic efforts to align such guidelines were largely absent at the system level, resulting in teamwork issues, confusion, and frustration. at hmh, our physician executive and chief medical officer have addressed this issue via regular and timely update communications. at the time of this writing, covid-19 has pushed the global economy to the brink of or already into a major recession. modifications of population dispersion (social distancing) and quarantine protocols, and a complete halt to large portions of the us economy, have resulted in unprecedented overall societal stress and anxiety. unfortunately, a disproportionate share of the sacrifice is borne by the portions of our population who are at greatest socioeconomic risk. while business is booming in health care, all indicators point to a likely sustained overall economic downturn. this undoubtedly contributes to health care workers' stress and anxiety. in addition, anecdotal and news report evidence suggests that some private anesthesia groups in the country have experienced financial distress, resulting in furloughs and layoffs because they depend heavily on providing services for routine, elective surgeries, which have been canceled or delayed in a number of states. 17 it is well documented that such uncertainty about future occupational stability (job security) is associated with a deterioration in mental well-being. 18 organizational adaptation and opportunities several traits of resilient performance and improvisation have been observed at hmh. the incident command team was rapidly assembled; leadershipemployee communication was constant and responsive; and human resources (hr) adapted policies to employee needs. to long-standing employees, these adaptations were not surprising, because our leadership and teams have literally weathered storms before, including in recent history, hurricane ike and hurricane harvey. hurricanes are not pandemics, but their local effects are similar in terms of financial and emotional strains on employees, as well as sudden geographical isolation of both employees and patients. in particular, the seamless way in which hmh executive leadership and hr adapted policies-including alternate paid time off options, advanced check dispersal with waived fees, telecommute policies, and waived copays for mental health services-was consistent with how the health system has previously assessed emerging disaster situations and responded with astute budget analyses to bolster employee bank accounts without breaking the hospital budget. likewise, procedures for maintaining sensitive research areas such as our animal laboratories, clinical trials, and expedited institutional review board (irb) approval mechanisms for disaster-critical research, much of which is now being implemented nationwide, are reminiscent of ride-out and recovery procedures already commonplace in a texas gulf coast medical center. these proactive, positive responses corroborate that the best way to weather a storm is to look where storms have repeatedly been weathered. in a more direct way, we have seen this for the covid pandemic in portions of asia like singapore and hong kong, which were previously affected most by sars and novel influenza a (h1n1pdm09) virus of 2009 (h1n1) avian influenza and have likewise adapted comparatively faster to covid-19. 19 digital communication tools have also shown promise in enabling remote work as well as intrainstitutional collaborative efforts. covid-19 has brought health care professionals together across cities, states, and countries. for example, in the greater houston area alone, there have been more than 200 intensivists, extracorporeal membrane oxygenation (ecmo) specialists, and other specialized providers communicating through popular social media platforms (eg, whatsapp) and learning from one another. in addition, this pandemic has opened the opportunity for innovations and adoption of alternative care delivery methods like telemedicine and virtual icus. hmh has been able to utilize these technologies for ecmotreated covid-19 patients and thus decreased traffic www.anesthesia-analgesia.org anesthesia & analgesia covid-19: lessons learned from an icu in and out of our icu patient rooms. resilience was also evident in the formation of interdisciplinary teams to design novel devices to help protect anesthesiologists in intubating covid-19-positive patients or persons under investigation. the covid-19 pandemic exposed several gaps in our health care system, including the need for proactive investment to increase large-scale epidemic and pandemic preparedness. the following recommendations are made to prevent burnout and mitigate occupational stress, especially among intensive care providers during a pandemic. • the national and regional disaster mitigation plans for future epidemics have to incorporate mechanisms to allow rapid and agile transformation of relevant industry to support massively increased demand for disinfectants, cleaning supplies, ppe, and other medical equipment for health care and community use. although certain industries and corporations have exhibited a heightened sense of responsibility during the current covid-19 pandemic, such efforts need to be preemptively planned, and specific industries should be earmarked, trained, and equipped for a rapid transformation. industries willing to step up in times of crises and invest in disaster readiness may be incentivized by tax breaks or other mechanisms. • access to updated information about the availability of covid-19 testing kits and ppe for health care workers may reduce the anxiety associated with uncertainty and reduce unproductive information seeking 20 and emotional distress. 21 daily rounds and huddles, along with communication technologies, such as huddle boards, can be used to serve as reliable information sources. • structured training on large-scale disaster management and response must be provided. the society of critical care management offers a fundamentals of disaster management course, which can build crucial mental models and support development of organization-specific structures for response management. 22 in addition, the federal emergency management agency (fema) offers a variety of free courses and resources. • disasters necessitate innovation. with the rise of covid-19, several innovative designs were proposed to protect the health care workers on the front lines from the rapidly and widely spreading virus. 23 however, there is a dearth of manufacturing capacity and materials to produce many of these solutions. systems of innovation that were developed and honed during other national emergencies when most resources were constrained (eg, the functional analysis systems technique [fast] developed during the manhattan project) 24 are being revisited to tackle the problem nationally and globally. we need these solutions to buy time for effective antiviral medications and a vaccine for covid-19. meanwhile, there is a need to provide technical oversight to ensure that new designs meet minimum safety requirements. for example, during this pandemic, an abundance of homemade masks and gowns were designed and adopted without proper attention to fit and leak protection, potentially leading to a false perception of protection among health care workers. • the united states has a well-trained yet largely untapped resource of medical professionals in the form of internationally trained physicians, nurses, medical technicians, and other health care providers. due to strict state licensing regulations, such individuals are barred from routine direct patient care. though we do not propose a blanket relaxation in medical licensure requirements, we feel it is imperative that willing and able individuals be periodically trained to maintain a medical reserve corps at the regional, state, and national level. we opine that the notion of wartime-like preparedness has to be a serious and deliberate consideration, and maintaining a readily deployable human capital reserve is part and parcel of such preparedness. • while studies emerged to investigate pandemicrelated mental health issues, 1 there is a need for feasible and practical methods to assess health care workers' fatigue and burnout. 25, 26 wearable sensors have shown promise 27 by providing an opportunity to monitor fatigue, stress, and sleep biomarkers noninvasively and then communicating this information to clinical unit managers for timely intervention. in addition, mobile health (mhealth) tools have shown promise to facilitate mental health self-management. simple methods such as breathing exercises, biofeedback, and mindfulness can be utilized to mitigate acute episodes of stress and anxiety, while telehealth services can be used to enable peer-support and occupational counseling. however, the integration of new technologies with current workflows may present additional burden and needs to be further examined. the lessons learned and documented here demonstrate that when confronted with seemingly inadequate xxx xxx • volume xxx • number xxx www.anesthesia-analgesia.org 5 federal-level logistics and response, it is perhaps time to recall the social virtues of local-level resilience and self-reliance. it is beyond the logistical capabilities of any government to provide what is needed to every citizen when the scope and magnitude of the disaster are beyond a localized event (eg, hurricanes, large-scale wildfires, and earthquakes). such disasters strain national capacity for response. it was local authorities, in many cases aided by private citizens, that kept us all together, as one (eg, the cajun navy's role during katrina 28 and houstonians' response during harvey 29 ). we can harness the government, industry, and individual efforts and resources to effectively mitigate such disasters and challenges. these efforts start with education and leadership that instill a sense of community and duty to the community, into the fabric of our society. pandemics of this scale occur roughly every 100 years, with more localized or less severe cases in the interim. 30, 31 we have learned from each of them, but we have still failed to devote enough of our public resources into providing adequate supplies and proactively planning to address these events. this is going to happen again, and it is our choice to act. e factors associated with mental health outcomes among health care workers exposed to coronavirus disease supporting the health care workforce during the covid-19 global epidemic about us: facts and statistics | houston methodist houston company ranks no. 1 in forbes list of best employers in texas. kprc covid-19) situation summary. cdc.gov layered use of nonpharmaceutical interventions. cdc cdc community mitigation guidelines work group. community mitigation guidelines to prevent pandemic influenza -united states the story behind "flatten the curve," the defining chart of the coronavirus. fast company state roundup: with a lack of compliance to social-distancing, gov. hogan orders all non-essential businesses shut new york city to fine people for violating social distancing rules 28 university of texas spring breakers test positive for covid-19 after group trip to mexico. nbc news florida college students test positive for coronavirus after going on spring break. cbs news the social-distancing culture war has begun. the atlantic covid-19) -interim guidance for businesses and employers recommended guidance for extended use and limited reuse of n95 filtering facepiece respirators in healthcare settings -niosh workplace safety and health topic. cdc.gov boise health care firm lays off 53 people. idaho statesman changes in mental well-being, blood pressure and total cholesterol levels during workplace reorganization: the impact of uncertainty singapore was ready for covid-19-other countries, take note. wired managing uncertainty in illness explanation: an application of problematic integration theory communicating crisis uncertainty: a review of the knowledge gaps students work to deliver automated bag valve mask to address covid-19 crisis function analysis and decomposition using function analysis systems technique design for stress, fatigue, and workload management physiological and psychological aspects continuous monitoring and detection of post-traumatic stress disorder (ptsd) triggers among veterans: a supervised machine learning approach how citizens turned into saviors after katrina struck voices: citizens with boats filled rescue void a year ago during hurricane harvey floods. usa today the mother of all pandemics is 100 years old (and going strong)! 100 years since 1918: are we ready for the next pandemic? influenza division the authors thank jacob m. kolman, ma (senior scientific writer, center for outcomes research, houston methodist hospital, houston, tx. contribution: content review and revision of the manuscript for flow and formatting). key: cord-350521-jfd5gd2p authors: bong, choon-looi; brasher, christopher; chikumba, edson; mcdougall, robert; mellin-olsen, jannicke; enright, angela title: the covid-19 pandemic: effects on lowand middle-income countries date: 2020-04-20 journal: anesth analg doi: 10.1213/ane.0000000000004846 sha: doc_id: 350521 cord_uid: jfd5gd2p coronavirus disease 2019 (covid-19) is spreading rapidly around the world with devastating consequences on patients, health care workers, health systems, and economies. as it reaches lowand middle-income countries, its effects could be even more dire, because it will be difficult for them to respond aggressively to the pandemic. there is a great shortage of all health care providers, who will be at risk due to a lack of personal protection equipment. social distancing will be almost impossible. the necessary resources to treat patients will be in short supply. the end result could be a catastrophic loss of life. a global effort will be required to support faltering economies and health care systems. mere anarchy is loosed upon the world. -william butler yeats, the second coming a s news of a novel viral illness in china emerged in january 2020 1 and until the day when the director general of the world health organization (who) declared a pandemic, 2 those who live and work in low-and middle-income countries (lmics) held their collective breath. as the single red dot on the world map morphed into red dots in almost every country in the world, the enormity of the problems facing all countries, but especially those with serious economic and health resource challenges, became evident. in this special article, we outline what those problems might be and possible ways to address them. the new coronavirus, officially named severe acute respiratory syndrome coronavirus 2 (sars-cov-2), probably emerged in november 2019 and first caused cases of pneumonia of unknown origin in wuhan, china. the spectrum of illness caused by sars-cov-2 is now called coronavirus disease 2019 . initially thought to be transmitted from an animal or bird source to humans, it is now clear that there is efficient and thus widespread human-to-human transmission via airborne droplets. despite a massive effort to contain the virus within china, it has disseminated throughout the world. as of march 23, 2020, there have been 334,981 confirmed cases, in 189 countries, with 14,652 deaths. 3 the clinical spectrum of the disease is quite variable, ranging from undiagnosed asymptomatic infection through mild upper respiratory infection to severe viral pneumonia leading to respiratory failure and death. 4 the incidence of respiratory failure in wuhan was 54% overall; of those patients who died, 98% had respiratory failure compared to 36% of those who survived. all of those who succumbed had sepsis, and 93% had acute respiratory distress syndrome (ards), while 42% of survivors had sepsis and 7% had ards. 4 also noted in this wuhan cohort was a 48% prevalence of comorbidities in those who died, most commonly hypertension, diabetes mellitus, and coronary artery disease. increasing age was also associated with increased risk of death. overall, in-hospital mortality rate was 28%, and for those requiring mechanical ventilation, it was 97%. the disease has spread rapidly throughout the world. 3 existing antiviral medications seem to be ineffective. 5 the number of deaths from covid-19 is staggering. italy, which has become another major epicenter of the outbreak, is reporting, as of march 21,2020, a total of 48,452 cases with 3770 associated deaths. 6 countries have closed their borders, enforced strict social isolation and quarantine procedures, and increased testing coronavirus disease 2019 (covid-19) is spreading rapidly around the world with devastating consequences on patients, health care workers, health systems, and economies. as it reaches low-and middle-income countries, its effects could be even more dire, because it will be difficult for them to respond aggressively to the pandemic. there is a great shortage of all health care providers, who will be at risk due to a lack of personal protection equipment. social distancing will be almost impossible. the necessary resources to treat patients will be in short supply. the end result could be a catastrophic loss of life. a global effort will be required to support faltering economies and health care systems. (anesth analg xxx;xxx:00-00) the covid-19 pandemic: effects on low-and middle-income countries for the virus. travel has almost ceased worldwide. businesses have closed, and economies are almost collapsing. yet it seems the virus continues to spread, and health care systems are being overwhelmed. 7 why are some countries responding better than others? china put in place extraordinary measures, including tracing and testing of covid-19 contacts, and major quarantine restrictions, which included a complete lockdown that prevented all travel and commerce in and out of the wuhan region. 8 normal life was basically suspended. in contrast, singapore seems to have done better with a much less severe approach. 9 singapore applied a comprehensive surveillance strategy early on in the outbreak, with rigorous tracing of all case contacts followed by rapid quarantining. it used widespread testing so a patient with any suspicion of covid-19 could be rapidly tested. strict infection control practices were instituted at health care facilities, and health care workers were provided with adequate personal protective equipment (ppe). communication of information to the population was clear and transparent. request for the public to exercise social responsibility in containing the spread of the virus was met with compliance. with these measures, singapore has been relatively successful in managing the outbreak; however, new cases are beginning to occur, likely from travelers returning home. as a result, singapore has now adopted more stringent measures on social distancing. in efforts to continue tracing covid-19 contacts, the government of singapore has developed a contact tracing app, "trace together," that works by bluetooth technology. 10 singapore will make this freely available globally. italy, on the other hand, has been ravaged by this disease. 6, 11 the mean age of those who have died has been 81 years, and more than two-thirds of these individuals were past smokers or had chronic disease such as diabetes mellitus, cardiovascular disease, or cancer. in spite of widespread aggressive measures imposed by the italian government, the incidence and death rate continue to rise. it is clear that, even in countries with strong economies and sturdy health care systems, there can be variable responses and case fatality rates with the outbreak. at this point, it seems that the sars-cov-2 has spread to almost every country in the world. 3 even though many lmics have closed their borders to prevent travel-related dissemination, it is merely a matter of time before community-level spread becomes the norm. 12 lmics frequently have large populations living in overcrowded conditions where "social distancing" is impossible to maintain, where clean water is rarely available in every household, and where supplies of hand sanitizer are impossible to find. thus people living in lmics will generally be unable to follow the usual public health advice on how to reduce the spread of virus and infection. mr cyril ramaphosa, president of the republic of south africa, accurately described the pandemic as a "national disaster." 13 one infected case in south korea was determined to have been responsible for 3900 secondary cases. 14 with such rapid, exponential spread, the situation in lmics, refugee camps, and war-torn regions will be catastrophic. health care facilities in lmics will be overwhelmed by patients with covid-19. they are already overcrowded with those suffering from pneumonia, human immunodeficiency virus (hiv), tuberculosis (tb), and malaria, and patients in need of surgical treatment. covid-19 testing will be useful in confirming that patients have a viral illness and therefore do not require precious antibiotics. hospital beds will be in short supply, but unlike well-off, high-income countries (hics), poorer countries will be unable to significantly reduce their surgical volumes to make room for covid-19 patients. this is because the largest segment of surgical volume in lmics is emergent and urgent surgeries that cannot be safely postponed. 15 moreover, a large percentage of these cases are patients undergoing cesarean deliveries. 15, 16 if cesarean deliveries are delayed or cancelled, there is a likely risk of worsening already high maternal and neonatal mortality rates. another major challenge will be the shortage of intensive care beds. 17 even if they were abundant, there is a significant shortage of resources such as oxygen, ventilators, infusion pumps, and all of the other necessities for taking care of patients with severe respiratory failure. 18 even water and electricity supplies cannot be relied on in lmics. that brings us to the most overwhelming shortage of all-namely, health care personnel, including physicians-especially, anesthesiologists, who are on the front lines of any pandemic like covid-19. 19 in many lmics, anesthesiologists take care of patients in intensive care units (icus). they will be called on to intubate sick patients in emergency departments and in the operating rooms, as will nonphysician anesthesia providers. these health care workers will be at extremely high risk for infection, as intubation is considered one of the highest-risk procedures when dealing with covid-19 patients. 20 lessons learned from the sars epidemic in 2003 included the importance of full personal protection when performing high-risk procedures. 21 this is already also clear from the current covid-19 pandemic, as there have been deaths of many health care professionals in both china and italy. 22, 23 adequate ppe is mandated in all available guidelines for managing covid-19 patients. 20 ppe is in enormous demand around the world, and procurement will thus prove especially difficult in lmics. the prospect of losing any of our already scarce colleagues to this disease is terrifying. just as the world was waking up to the necessity of having safe anesthesia and surgery as part of universal health care, 24, 25 all of the efforts may be sidelined or derailed by an enemy <1 μm in diameter. in the midst of their own crisis, well-resourced governments and organizations should remember the needs of those less well-off. economies will be devastated all over the world. this is the time to consider debt erasure for countries most in need. the international monetary fund has committed us $10 billion in interest-free loans to low-income countries. 26 the united nations has released emergency funds to assist vulnerable countries in the fight. 27 much more will be needed now and in the foreseeable future. the world economic forum has launched a covid action platform to pull together a public-private partnership to support action on the pandemic. 28 it is likely that a fund similar to the global fund for hiv/acquired immune deficiency syndrome (aids), tb, and malaria will be needed to further support the development of medications and vaccines for covid-19. a fund such as the us president's emergency plan for aids relief (pepfar) will be required to provide medications and vaccines when they become available. pepfar is the largest commitment ever made by 1 government to address a single disease. nongovernmental organizations (ngos) that normally work in low-income countries also need to offer support and practical help. for example, the lifebox foundation, partnering with smile train and gradian health care, has secured 1650 pulse oximeters for distribution to countries most in need (k. torgeson, ceo lifebox, personal communication, march 23, 2020) . since most of the complications of covid-19 are respiratory, pulse oximeters will be essential in the management of patients. however, without reliable oxygen supplies, oximeters will not help. massive efforts will be needed to improve oxygen availability. these will include not only a steady supply of oxygen tanks with a reliable delivery service but also provision of new oxygen concentrators and regular maintenance of those already available. without oxygen, many lives will be unnecessarily lost. doctors without borders (médecins sans frontières, msf) is providing health education activities, distributing soap and ppe for health care workers, and reinforcing hygiene measures in all of its facilities. 29 will other ngos step up to help? governments, departments of health, and medical professional organizations need to be providing clear and unequivocal information about covid-19: how to prevent its spread, who needs to be tested for it, and how to manage it if one becomes infected. one of the major problems for lmics is communication. radio, television, and newspapers are no longer the main methods of conveying information. social media in all of its forms is much more likely to carry the message. who has recognized this and launched a messaging service in conjunction with whatsapp and facebook. 30 people can access the service, ask questions, and get advice. many journals, for example, the lancet and the new england journal of medicine, are publishing all articles on covid-19 with free access to everyone. 31, 32 the same is true for anesthesia journals like anesthesia & analgesia. likewise, the cochrane library is available for unrestricted access for all, with special collections on infection control measures and evidence relevant to critical care. 33 uptodate (wolters kluwer, waltham, ma) is also providing open access to clinical content on covid-19. 34 there are many advisories and guidelines available on the management of covid-19 patients in the icu and operating suite. 35, 36 most of them apply to countries with significant resources and strong health care systems. they often include links to other useful sites for information. for example, reference 28 includes links to the who site, the us centers for disease control and prevention (cdc), and the public health agency for canada, all of which have very useful information available. most lmics will have to adapt these resource documents to their needs and to the availability of equipment and resources at their centers. we are including 1 table and 2 figures that may be useful for those working in areas where resources are scarce. the table emphasizes the key points in managing patients. figure 1 offers some low-cost suggestions for creating or extending ppe. figure 2 offers recommendations on oxygen therapy. in addition, we are recommending applying a very useful system for those working in icus. 37 this rubric is very practical and contains many educational materials filed under an a, b, c system. the african federation for emergency hand washing: soap and water; alcohol-based sanitizer 2. dedicated triage and inpatient areas for covid-19 patients 3. personal protective equipment: practical, locally sourced 4. therapeutic plan: locally devised, known to and agreed on by all staff 5. oxygen: increased supplies, maintenance of existing sources medicine has also prepared a useful booklet for those working in lmics. 38 unfortunately, there are no medications demonstrated to successfully treat covid-19. work continues apace to find them. false claims may be made, which can result in fatal outcomes. 39 in addition, normal medication supply chains may be severely affected by the worldwide shutdown of factories, leaving many patients unable to access their normal medication supplies. 40 current treatment is supportive. in many mild cases, people may convalesce at home. however, the severe cases are placing enormous strain on hospitals because of their growing numbers and the large percentage of patients who are requiring intensive care management. these severe cases are posing the greatest threat to health care workers in terms of cross-infection, and their resource needs will outstrip those available in many low-resource environments. there will be many ethical challenges to be faced. guidance is available from several sources, 41 and we suggest having clear agreement on the relevant issues as soon as possible. each center will have to make its own decisions based on its currently available resources. to answer this question, we can only rely on what has been learned from the ebola epidemic of 2014-2016 in west africa. according to a report of the united nations development group (undg), at that time, the epidemic was "the longest, largest, deadliest and most complex" in history. 42 covid-19 is already orders of magnitude greater than this. the us cdc estimates that there were just under 29,000 infected patients and just over 11,000 deaths during the ebola epidemic of 2014-2016 in west africa. 43 liberia lost 8% of its doctors, nurses, and midwives; sierra leone 7%; and guinea 1%. the epidemic set back the management of all health care services and especially treatment and control of tb, hiv, and malaria. the number of women giving birth in health centers in sierra leone dropped by 30%; cesarean delivery rate dropped by 60%. 44 it is estimated that $2.2 billion was lost from the gross domestic product of the 3 countries. the united states, the united kingdom, and germany donated over us $3.5 billion in aid. 43 the undg observed that "the global community is ill prepared for a devastating pandemic like ebola, and the next pandemic should not take the world by surprise." 42 how correct this prediction has been. another lesson to be learned from the ebola epidemic has to do with "health security." this will not be a term familiar to most people, but it certainly will become so. basically, health security means protection from threats to our health. 45 with modern travel and globalization, an epidemic in west africa or china, or anywhere else in the world, can easily become a threat in another location far away. thus it is imperative that governments and supranational organizations like the who work together to reduce the risks everywhere. there are international health regulations that aim to stop the spread of infectious diseases. 46 however, they need to be expanded and modernized to address the issues of our time. "collective health security is the sum of individual health security, and compels global action to provide individuals in all countries with access to essential health care. this is indispensable for achievement of individual health security and, therefore, collective health and human security." 45 in the absence of specific, effective treatment and given a lack of resources in managing active covid-19 patients, prevention and early containment of the disease appear to be the most feasible option for lmics. as the global covid-19 situation unfolds and countries are forced to take unprecedented drastic measure, including border closures, travel bans, and social distancing, we will likely witness the devastating and profound impact of this pandemic not only in health care but also on the world economy. this will further reduce resources available for health care, not just in managing covid-19 patients, but also for those with many other major medical conditions. this will be particularly challenging for lmics. the recent catastrophic clinical scenarios in many hics, including italy, spain, france, the united states, and the united kingdom, caused by a shortage of ppe, as well as other vital material and human resources, are a solemn reminder that many lmics will be facing similar or likely much worse constraints and outcomes. in the midst of all this doom and gloom, thousands of volunteers work tirelessly to ensure that food and medical supplies reach the millions of our fellow human beings in lmics who need them. increased connectivity allows rapid sharing of information and resources, all of which could help in "flattening the curve" in an attempt to avoid overwhelming individual health care systems. in the end, we must rely on the generosity of mankind and the resilience of the human spirit. e specter of possible new virus emerging from central china raises alarms across asia tor-general-s-opening-remarks-at-the-media-briefing-oncovid clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study covid-19 -the search for effective therapy integrated surveillance of covid-19 in italy upward trajectory or flattening the curve? 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