COVID-19 and Clinical Care
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1. Is ASA advocating use of a video laryngoscope as first line for intubation? We have a very limited supply of sleeves at my institution.
- We recommend that providers perform intubations with the greatest chances of success on the first attempt. This must be balanced with the supply chain availability. We also recommend close collaboration with your healthcare system to closely monitor the supply chain and determine how best to utilize limited resources. Please see the recommendations on intubating COVID positive and suspected COVID positive patients.
2. Does ASA recommend a specific course of action or treatment for COVID-19 patients in the Intensive Care Unit?
- As a medical association, we cannot make specific medical recommendations for patients. We likewise do not track how physicians treat or may have treated individual patients.
- However, we have provided, in collaboration with the Society of Critical Care Anesthesiologists (SOCCA), the Society for Critical Care Medicine (SCCM) and APSF, a number of educational and training resources for members to use. This material is known as the COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU Project.
3. Where can I find ASA Critical Care education and training resources?
4. How do we assess drug supplies during the use for ventilated COVID patients?
- Assessment of drug supplies requires close coordination with your pharmacy and pharmaceutical distributers to identify current rates of medication utilization with days of supply on hand. The ASA Committee on Critical Care Medicine has published drug recommendations for COVID-19 during times of drug shortages.
5. What are some considerations for the treatment of obese ICU patients?
- The ASA Committee on Critical Care Medicine discussed the ramifications of the obese population and diabetic population in the US on the management of patients infected with Covid-19. Patients with obesity or type 1 or type 2 diabetes make up roughly 33% and 9% of the US population respectively.1, 2
- Diabetic patients do make up a substantial portion of patients hospitalized with Covid-19 (up to 19-58%).1,3 Diabetes has been demonstrated to be a risk factor for acute kidney injury in ARDS in the general population while acute kidney injury (AKI) appears to occur in about 15% of Covid-19 patients4. Diabetes itself is associated with increased ACE2 receptor expression which is the receptor that Covid-19 binds to in order to facilitate disease and impairs immunity5.
- The clinical experience of the Committee on Critical Care Medicine thus far further suggests that patients who are morbidly obesity are doing worse in that they are very difficult to ventilate and are requiring deeper sedation and more frequent paralysis. Additionally, they appear to have a higher rate of AKI. Lastly, critical care myopathy (weakness), which is classically associated with prolonged neuromuscular blockade) also effects the ability of morbidly obese patients to successful extubation. Please note that the overall clinical experience with extubation appears limited at this point.
- There appears to be less clinical experience within the committee specifically pertaining to diabetes mellitus, but as it is extremely common, any significant patterns may not yet be obvious. There is not a clear treatment pattern in the literature for the diabetic population. An executive summary of the consensus of the committee on critical care medicine is as follows:
- Preventive measures before obese patients becomes critically ill are likely the most effective means to reduce morbidity in these patients.
- While on the floor, medical teams can remind patients to put themselves in prone position at regular intervals and/or walk a specified number of laps in the patient’s hospital room based on their condition.
- Forethought pertaining to teaching the patient to make themselves prone can prevent the nurse from having to enter the room as well, thus conserving PPE.
- Creative thinking/positioning with pillows but our hope is that patients can do this themselves without requiring nursing to come in.
- Consideration may be given to implementing prone positioning in the EMS setting if feasible and further clinical data supports it.
- Once mechanically ventilated, challenges in ventilation may be expected but not necessarily preventable at this stage. Prone positioning should be continued but may be more challenging for staff.
- Patients with diabetes may be at higher risk for morbidity, but there does not yet appear to be a way to mitigate that risk.
- Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, Greninger AL, Pipavath S, Wurfel MM, Evans L, Kritek PA, West TE, Luks A, Gerbino A, Dale CR, Goldman JD, O'Mahony S, Mikacenic C: Covid-19 in Critically Ill Patients in the Seattle Region - Case Series. N Engl J Med 2020
- De Jong A, Chanques G, Jaber S: Mechanical ventilation in obese ICU patients: from intubation to extubation. Crit Care 2017; 21: 63.
- Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B: Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054-1062.
- Panitchote A, Mehkri O, Hastings A, Hanane T, Demirjian S, Torbic H, Mireles-Cabodevila E, Krishnan S, Duggal A: Factors associated with acute kidney injury in acute respiratory distress syndrome. Ann Intensive Care 2019; 9: 74.
- Muniyappa R, Gubbi S: COVID-19 Pandemic, Corona Viruses, and Diabetes Mellitus. Am J Physiol Endocrinol Metab 2020.
6. How long are you able to keep a patient continuously ventilated on an anesthesia machine without disconnecting to change circuit, run machine check, change the filters?
- Since there are numerous makes and models of anesthesia machines, ASA recommends discussing these concerns with the manufacturer’s technical services. Anesthesiologists are well-trained to balance the risks and benefits on an individual basis for patients under their care.
- ASA and APSF have written guidance on the use of anesthesia machines as ICU ventilators. These guidelines suggest disconnecting the patient at least every 72 hours to restart the anesthesia machine and perform a startup test. A step-by-step procedure for doing this is provided. Loss of lung volume is prevented by briefly clamping the endotracheal tube when it is disconnected. The breathing circuit and filters can be changed during this time. Additionally, filters may need to be changed more frequently when they become partially obstructed. To support patients during the anesthesia machine power up test, please refer to this Startup-Test Checklist (PDF) for step-by-step guidance.
7. Does ASA have any suggestions about performing tracheotomies on COVID-19 patients?
- We cannot provide clinical recommendations regarding an appropriate time frame for or testing prior to this procedure. We instead recommend consulting with local infectious disease experts and infection control staff. Tracheostomy would be considered a high-risk procedure and risks and benefits should be considered based upon individual patient care and need (e.g. FiO2, oxygenation and PEEP). We recommend physicians considering this procedure review guidance provided by the American Academy of Otolaryngology-Head and Neck Surgery: Tracheotomy Recommendations During the COVID-19 Pandemic.
- Performing a tracheostomy is an aerosol generating procedure (AGP), and open tracheostomies generate respiratory droplets and aerosols at a high rate. Tracheostomies, when performed, should follow a protocol such as described in this 2003 study entitled “Safe tracheostomy for patients with severe acute respiratory syndrome.” Please also review the recent article, “Perioperative Considerations for Tracheostomies in the Era of COVID-19.”
8. What are some elements of patient blood management that I should consider?
- The ASA Committee on Patient Blood Management has developed a resource for anesthesiologists with regard to pandemics and patient blood management. The resource also includes references and links to relevant literature.
9. Are there specific recommendations for EGD procedures and other procedures with a high risk of aerosolization?
- Decisions need to be based on an understanding of your local COVID-19 risk profile for community spread in your area in consultation with your local infectious disease and infection control experts. This information will help inform your own risk assessment development considering the patient, skill sets of the endoscopists and local resources. ETTs provide the most secure airway. Airway masks with apertures for gastroscopes such as a POM (Procedural Oxygen Mask by Curaplex) or similar masks may limit dispersion as an alternative when supplies of N95 are low. ASA has also released guidance for procedures where there is a high probability of aerosolization. Physicians may wish to consult recent gastroenterology consensus documents or conduct an independent literature review for more information.
10. What is the recommendation for LMA usage or MAC anesthesia? Should we presume all patients are carriers and therefore LMA usage and MAC anesthesia be minimized?
- Since March 2020, anesthesiologist experiences in treating COVID-19+, COVID-19 negative, PUI and asymptomatic patients have increased and standard operating procedures have been reevaluated at local facilities. When considering LMA use, we recommend a risk assessment be performed based on the COVID community-wide transmission. We also recommend that anesthesiologists, when determining airway techniques and anesthetic choices, take into consideration the results of a patient’s COVID-19 test, including the sensitivity and specificity of tests being used, and balance testing and community spread with choosing the appropriate PPE to use. Anesthesiologists may wish to discuss policies with local infection prevention experts.
- PPE for aerosol-generating procedures should be worn. Airway cases, upper endoscopy, bronchoscopy, and situations that induce cough or sneeze should be considered as high risk for aerosol production. There is potential risk for other providers who are present near the oropharyngeal airway as well, and gastroenterologist society recommendations warn of risk with upper and lower GI endoscopy.
- For anesthesia professionals, an additional consideration is that a failed MAC case may need to be transitioned rapidly to tracheal intubation that likely bears higher risk for suboptimal conditions.
11. What should we do about “MAC” cases, with an open airway?
- If dispersion of potentially contaminated exhaled gases from an open airway (e.g. “MAC”) in a patient with COVID-19 is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should also be considered. The safety of you and your colleagues is paramount.
12. What contingencies should an anesthesia professional use when considering using an LMA with positive pressure ventilation versus an endotracheal tube in a standard operating room (positive pressure room)?
- We recommend that anesthesiologists and anesthesia professionals, when determining airway techniques and anesthetic choices, take into consideration results of a patient’s COVID-19 test, the sensitivity and specificity of testing being used, and community spread. Based upon these criteria, anesthesiologists and other anesthesia professionals can determine whether a conservative or more liberal approach is necessary, especially if there is high community spread. In assessing risk of exposure, anesthesiologists should also consider whether individual LMA, MAC and regional cases would have a risk for general anesthesia conversion.
13. How should I deliver supplemental oxygen to a COVID+ or PUI patient who is wearing a mask?
- If a patient has or is likely to have COVID-19, the first consideration is for your safety and the safety of everyone in the room. It is important that you wear appropriate PPE. Being at the COVID-positive patient’s head, there is always risk of coughing and of needing to physically support the airway with jaw thrusts or intermittent positive pressure ventilation by face mask. Therefore, PPE for aerosol-generating procedures should be worn. There will be insufficient time to garb if there is an urgent clinical development. For the patient, nasal prongs under surgical mask with low-flow oxygen or simple face mask over surgical mask might suffice. However, if patient oxygenation is not maintained on low-flow oxygen, higher oxygen flows may be unexpectedly needed that might increase aerosolization of COVID-containing respiratory secretions. Each patient will need to be evaluated on a case-by-case basis to consider the balance of aerosolization at the oxygen flow needed to maintain a satisfactory oxygen saturation, and whether to convert to a more closed airway system (LMA or ETT).
14. Does ASA have any recommendations for performing steroid injections in the elderly population with COVID-19?
- We do not have specific guidance on epidural steroid injections and COVID-19 with regard to individual patient medical histories. We recommend that you assess each patient and also consider decreasing the dose of steroid administered, keeping in mind that the effect of the long acting steroids will last for a while in your patient.
15. What considerations should I have for developing an anesthesia plan for ECTs?
- We realize that ECTs are likely a time-sensitive case with a high risk of aerosolization. At the same time, anesthesiologists are trying to balance the benefit of the case with the risk of COVID-19 transmission. Based upon community spread and other risk factors, we recommend the use of PPE for aerosol-generating procedures, including those for COVID-19 and suspected COVID-19. Viral filters should be used for known and suspected COVID patients. Please review the APSF website for further information on filters, including how to extend filter use.
16. Does ASA have any guidance on the treatment of stroke patients during the COVID-19 pandemic?
17. Does ASA have a position on safety of regional anesthesia vs general anesthesia for COVID-19+ and PUIs?
18. Does ASA have any recommendations for overall obstetric care and specifically epidurals and spinals?
- ASA members are encouraged to review the recent statement published by the Society for Obstetric Anesthesia and Perinatology (SOAP). regarding obstetric care. In general, we are unaware that coronavirus is a contraindication to a neuraxial block. Spinals and epidurals should take into consideration appropriate precautions, especially regarding COVID-19 patients or those suspected of having COVID-19. Such precautions may include isolating the infected or suspected patient and placing them in rooms identified for that purpose as well as having a dedicated operating room. Ideally, these operating rooms would be negative pressure rooms. We also recommend the use of N95 masks, double gloves, gowns and protective eyewear as appropriate.
19. Does ASA have any recommendations regarding pediatric airway management?
20. Does ASA have any clinical recommendations on anesthetizing a patient who previously had COVID-19?
- We cannot comment on individual patients or specific procedures. The recommendations to delay care, when possible, to COVID-19 positive patients are to ensure patients are optimized for surgery. At this time, there are few studies and consensus on how best to provide perioperative management of patients recovering from COVID-19. However, we would recommend that anesthesiologists remain vigilant for ongoing physiologic changes that may have occurred with COVID exposure including, but not limited to, hypercoagulability and cardiopulmonary changes.
Viewers of this material should review these FAQs with appropriate medical and legal counsel and make their own determinations as to relevance to their particular practice setting and compliance with state and federal laws and regulations. The ASA has used its best efforts to provide accurate information. However, this material is provided only for informational purposes and does not constitute medical or legal advice. This response also should not be construed as representing ASA policy (unless otherwise stated), making clinical recommendations, dictating payment policy, or substituting for the judgment of a physician and consultation with independent legal counsel.