Airway management for known or suspected covid.

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anes121508

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How are you guys specifically doing this or planning on it?

I’m talking specific institutional protocols.

If get ours I will post it.

Should we be sharing best practice and help editing stuff?

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Yes please. I will post ours when we have it. For what it’s worth the WHO recommendations are :
RSI with glidescope only using a bougie to increase your distance from the mouth as much as possible. No BVM, no cpap, no high flow nasal canula.
 
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Wait, if I have a glidescope how does the bougie get me further away? I still have to put the glidescope in their mouth.
 
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Yes please. I will post ours when we have it. For what it’s worth the WHO recommendations are :
RSI with glidescope only using a bougie to increase your distance from the mouth as much as possible. No BVM, no cpap, no high flow nasal canula.

Can you link to a reference for WHO recommendations? I'd like to share with a colleague. Thanks
 
Wait, if I have a glidescope how does the bougie get me further away? I still have to put the glidescope in their mouth.

I'm going to supervise a CRNA from 50 feet away. That should keep me fairly safe :)
 
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Maybe I’ll call the ER and see if there’s any paramedics that would like some airway experience.
 
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The intubation should be done by the most experienced provider (decreases exposure risk for everybody).
 
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We’re doing induction and intubation (RSI with glidescope) in a negative pressure room with only essential staff (anesthesiologist, circulator) present. Anesthesia tech will be right outside with full complement of possibly necessary equipment.
Once intubated will place an antiviral filter on ETT and transport to designated OR. All imminently essential equipment remains in OR with a tech or CRNA just outside to toss anything that may be needed into the room.
After case transport back to negative pressure room for extinction (or transport to ICU).
We’re using N95, face shield, gowns, gloves, shoe covers. We have a limited number of PAPRs but unlikely to use them in the OR.
 
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We’re doing induction and intubation (RSI with glidescope) in a negative pressure room with only essential staff (anesthesiologist, circulator) present. Anesthesia tech will be right outside with full complement of possibly necessary equipment.
Once intubated will place an antiviral filter on ETT and transport to designated OR. All imminently essential equipment remains in OR with a tech or CRNA just outside to toss anything that may be needed into the room.
After case transport back to negative pressure room for extinction (or transport to ICU).
We’re using N95, face shield, gowns, gloves, shoe covers. We have a limited number of PAPRs but unlikely to use them in the OR.

For all cases or just those of suspected COVID19?

Edit: Nevermind, I saw the title of the thread.
 
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For all cases or just those of suspected COVID19?
I would do it for all. There are more and more asymptomatic carriers (spreading the virus) out there. Plus, by doing it even for low-risk patients, it becomes routine and decreases the risk of contagion for high-risk intubations. Which are coming, don't doubt it.
 
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I would do it for all. There are more and more asymptomatic carriers (spreading the virus) out there. Plus, by doing it even for low-risk patients, it becomes routine and decreases the risk of contagion for high-risk intubations. Which are coming, don't doubt it.
That sounds nice, but for those of us in systems where they haven't shut down elective cases yet we would blow through all PPE supplies in days. I made the joke earlier today that when I get it, just leave me in the hospital. Anytime a suspected case needs intubated I'll just hold my breath while I run to the room, do the intubation like usual, then hold my breath on the way back to my own room.
 
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That sounds nice, but for those of us in systems where they haven't shut down elective cases yet we would blow through all PPE supplies in days. I made the joke earlier today that when I get it, just leave me in the hospital. Anytime a suspected case needs intubated I'll just hold my breath while I run to the room, do the intubation like usual, then hold my breath on the way back to my own room.
You should protest against the stupidity and greed of your leadership. You're putting both patients and healthcare workers at risk. You simply can't tell who has Covid already.

There are probably tens (if not hundreds) of thousands of infected people out there already (we have 4400 confirmed in the whole US as of today). If you pass it on to an elderly patient, you may as well sign their death warrant.

No, I'm not exaggerating.
 
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You should protest against the stupidity and greed of your leadership. You're putting both patients and healthcare workers at risk. You simply can't tell who has Covid already.

There are probably tens (if not hundreds) of thousands of infected people out there already (we have 4400 confirmed in the whole US as of today). If you pass it on to an elderly patient, you may as well sign their death warrant.

No, I'm not exaggerating.
I have been as much as a senior resident can. I'm with you 100%
 
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If you pass it on to an elderly patient, you may as well sign their death warrant.

While I don’t necessarily disagree with the point you’re making, a mortality rate of 10-15% in those over 80 is hardly “signing their death warrant.”

Let’s try to keep the drama on social media where it belongs.
 
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While I don’t necessarily disagree with the point you’re making, a mortality rate of 10-15% in those over 80 is hardly “signing their death warrant.”

Let’s try to keep the drama on social media where it belongs.
Nobody over 80 among your dear ones? Also, it's not the healthy 80 year-olds an anesthesiologist is most likely to encounter. And 15% is the number only as long as we have enough equipment/healthcare workers.

Let me put it another way: if you knew that by isolating you are saving just ONE life, somebody else's (grand)parent, wouldn't you? I am sure you would.

Just sayin'... :=|:-):
 
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Let me put it another way: if you knew that by isolating you are saving just ONE life, somebody else's (grand)parent, wouldn't you?

Now that’s a much better less sensationalistic way to put it :thumbup:

I didn’t disagree with your message, just your over the top delivery.
 
Now that’s a much better less sensationalistic way to put it :thumbup:

I didn’t disagree with your message, just your over the top delivery.
I am thinking in epidemic terms already, sorry. We may get to the point where those 80 year-olds don't even get a (ICU) bed, in parts of the country. Hopefully the Italian experience will remain in Italy.
 
After case transport back to negative pressure room for extinction.

Sure seems like a lot of work just to finish them off like the dinosaurs afterward ;)
 
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Was just thinking about this, and I had an idea.
what do you guys think of giving glycopyrolate pre induction?
reduce the secretions, reduce the chance you need suction?
 
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Was just thinking about this, and I had an idea.
what do you guys think of giving glycopyrolate pre induction?
reduce the secretions, reduce the chance you need suction?
You need 20 minutes or so, for it to really work.
 
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It's OK guys. The AANA released a statement saying to treat any patient as if they have COVID and use N95 masks. Shortage be damned.
 
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I am not routinely familiar with antiviral filters. Are these good for days/weeks? Do these capture smaller particles that an HME does not?
 
Known or suspected by ID team:
- negative pressure room for airway
- no nebulizers
- one provider in room (saves resources and limits exposure), one provider immediately outside on standby ready to help
- full ppe : papr or n95 , double glove, cap, shoe cover?, yellow gown
- set up for first pass success: positioning, glidescope, bougie nearby
- preox: anesthesia circuit, good seal held by patient, no cpap (?told this is bad?), reverse t berg position and apneic oxygenation with nasal cannula for delaying time to desat, debating high flow, absolutely no bipap?
- RSI, (no cricoid pressure since one provider for full stomachs and those that would otherwise need RSI)
- if cant get airway alone second person enters
- if patient desats and you absolutely have to get sats up, LMA before BMV
- deglove outter pair
- blow up cuff
- attatch viral filter to ETT and connect to vent
- disposal of ppe carefully into touch free wastebasket
- no chest compressions if patient codes prior to tube being placed after induction

patients needing OR with known or suspected to be transported with filter and ambu to OR after being intubated in negative pressure room
directly to ICU intubated after case
 
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Plan for Urgent Cases that are unconfirmed and not suspected clinically

- treating same except for negative pressure room given limited rooms
- adjust as we know more about who may and may not be exposed and we have testing available
- we are being told people could be infectious despite symptoms and given lack of testing and knowledge who knows who has it?

No LMAs for these urgent cases

MAC on case by case basis, strongly encouraging regional
 
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I am not routinely familiar with antiviral filters. Are these good for days/weeks? Do these capture smaller particles that an HME does not?

MC-750 Straight HMEF
99.99% Bacterial/Viral Efficiency
Electrostatic Media
HME media treated with physiologically safe calcium chloride
30.4 mg/H2O Humidity Output @ VT 500ml
Resistance @ 60LPM - 148pa
Tidal Volume = 150 - 1500ml
Deadspace = 22.5ml
Weight = 18.8g
With luer sampling port
15F/22M - 15M - ISO Connections
 
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Proven efficiency The Intersurgical range of breathing filters has been designed for the protection of the patient, breathing system and equipment. They have been independently tested and proven to be highly efficient in preventing the passage of bacteria and viruses. Clinically relevant testing is carried out on all products using Bacillus subtilis (1.0µm x 0.7µm) and Ø174 bacteriophage. Additional testing includes Mycobacterium tuberculosis (0.3µm x 1.0µm), Hepatitis C (0.03µm) and MS-2 coliphage (0.02µm). These tests provide you with clinically relevant information to allow evidence-based decisions to be made on the most appropriate product to meet your clinical requirements.
 
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1584412824336.png
 
Was just thinking about this, and I had an idea.
what do you guys think of giving glycopyrolate pre induction?
reduce the secretions, reduce the chance you need suction?
an antisialogogue doesnt do a whole lot for edema and proteinaceous exudates in the airway, which are the reasons you're intubating in the first place, but knock yourself out....
 
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This may be a little over the top- any consideration in intentional over inflation of the cuff?
 
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It's OK guys. The AANA released a statement saying to treat any patient as if they have COVID and use N95 masks. Shortage be damned.

Many patients will be asymptomatic and unsuspected. My department is requesting the same thing.
 
Known or suspected by ID team:
- negative pressure room for airway
- no nebulizers
- one provider in room (saves resources and limits exposure), one provider immediately outside on standby ready to help
- full ppe : papr or n95 , double glove, cap, shoe cover?, yellow gown
- set up for first pass success: positioning, glidescope, bougie nearby
- preox: anesthesia circuit, good seal held by patient, no cpap (?told this is bad?), reverse t berg position and apneic oxygenation with nasal cannula for delaying time to desat, debating high flow, absolutely no bipap?
- RSI, (no cricoid pressure since one provider for full stomachs and those that would otherwise need RSI)
- if cant get airway alone second person enters
- if patient desats and you absolutely have to get sats up, LMA before BMV
- deglove outter pair
- blow up cuff
- attatch viral filter to ETT and connect to vent
- disposal of ppe carefully into touch free wastebasket
- no chest compressions if patient codes prior to tube being placed after induction

patients needing OR with known or suspected to be transported with filter and ambu to OR after being intubated in negative pressure room
directly to ICU intubated after case
The one thing I would say is that almost every policy/recommendation I've seen recommended avoiding NIPPV and especially HFNC due to increased aerosolization of the virus.
 
That sounds nice, but for those of us in systems where they haven't shut down elective cases yet we would blow through all PPE supplies in days. I made the joke earlier today that when I get it, just leave me in the hospital. Anytime a suspected case needs intubated I'll just hold my breath while I run to the room, do the intubation like usual, then hold my breath on the way back to my own room.
You could probably last quite a while with a little preoxygenation too!
 
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Was just thinking about this, and I had an idea.
what do you guys think of giving glycopyrolate pre induction?
reduce the secretions, reduce the chance you need suction?
For the first 20 years of my career, every patient got atropine or glyco pre-induction.
 
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How are those still doing elective cases handling LMA cases. ETT , spinal ?


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You're ahead of the game man. Impressive
Not sure whether it was sarcastic. I'll give you the benefit of the doubt. :)

I did read/listen to a bunch of stuff in the last two days, so I am somewhat more in an "Italian" mode. Italians keep repeating that their biggest mistake was underestimating what was coming, and that isolation is paramount. I am also an intensivist, so I know enough epidemiology to agree with them 100%.

Along those lines, food for thought for the "pragmatic" crowd:

My parents are elderly. I wouldn't want to lose them over a nanobeing. If others don't care about their own, maybe they are the ones who deserve to be "naturally selected", not their and others' (grand)parents. I didn't become a doctor to play Mengele (decide who lives and who dies).

There is no "proper" age to die. RBG is proof. Approaching 90, still sharp like a tack. Many others like her. Think Warren Buffett, Charlie Munger. All these people still have wisdom to impart, families to make happy. Unless it's futile care, it makes sense to help them.
 
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Sarcasm? No, no...
You are definitely ploughing a new furrow here.
You want to phone up the Who to tell them your findings?
 
Sarcasm? No, no...
You are definitely ploughing a new furrow here.
You want to phone up the Who to tell them your findings?
Nope. I just want to put you back on Ignore, where you were for a long time (for other reasons). That's my waiting list for the Dunning-Kruger-type wiseguys.
 
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How are those still doing elective cases handling LMA cases. ETT , spinal ?


Sent from my iPhone using Tapatalk

This applies to not only elective.

We have urgent cases that would typically be spinal.

Urgent cases that would be lma

Urgent cases that would be sedation.

I’m being told from ID:
If we assume the virus is out there and we can’t detect and they could be asymptomaic and contagious then we need precautionary measures.

Masking and bipap is bad and produces aerosols and exposes staff in room that may not have n95 on.

So what do we do with sick tavr that needs it done? Geta with rsi poses some risk. However, so does the oversedated tavr with limited resp reserve that desaturates and needs masked.

How about the 90 yo hip?

TEE for endocarditis?

Lvad with bad rv and has rectal bleeding needing colonoscopy?
 
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This applies to not only elective.

We have urgent cases that would typically be spinal.

Urgent cases that would be lma

Urgent cases that would be sedation.

I’m being told from ID:
If we assume the virus is out there and we can’t detect and they could be asymptomaic and contagious then we need precautionary measures.

Masking and bipap is bad and produces aerosols and exposes staff in room that may not have n95 on.

So what do we do with sick tavr that needs it done? Geta with rsi poses some risk. However, so does the oversedated tavr with limited resp reserve that desaturates and needs masked.

How about the 90 yo hip?

TEE for endocarditis?

Lvad with bad rv and has rectal bleeding needing colonoscopy?
Our total "sedation" for TAVR is a very low dose infusion of precedex. No apnea or hypoxia here.
 
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