Airway management for known or suspected covid.

[deleted697535]

They're good cases to talk thru!

A question. Who 'needs' a tavr right now?

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[chocomorsel]

Sarcasm? No, no...
You are definitely ploughing a new furrow here.
You want to phone up the Who to tell them your findings?

Ploughing a new furrow? Must be an English term. I should know this....

 

[vector2]

We've canceled truly elective cases but still have 4-5 rooms worth of urgent or non-urgent but also not truly elective cases going. Are you guys masking or placing LMAs in people with no symptoms?

 

[MirrorTodd]

Doing primarily cardiac stuff now. Still masking , although we basically always rsi them anyway. Incidentally, did a tavr today (guy was 140-someodd kgs), so we rsi, intubated, covid wasn't on my mind. Also, incidentally, something perfed in his heart cause we had to code him and very nearly crashed onto bypass (got him heparinized). After ROSC, they then did an echo and pericardiocentesis and pulled 700ml out. Pretty ****ing hairy.

 

[nimbus]

We've canceled truly elective cases but still have 4-5 rooms worth of urgent or non-urgent but also not truly elective cases going. Are you guys masking or placing LMAs in people with no symptoms?

Never masked before COVID. See no reason to start now.

 

[anes121508]

They're good cases to talk thru!

A question. Who 'needs' a tavr right now?

everyone according to our cards guys

 

[anes121508]

Our total "sedation" for TAVR is a very low dose infusion of precedex. No apnea or hypoxia here.

Agree. Wish I could say that for all providers.

Devils advocate:
What happens when the TAVR , that could be done in 3-6 months, turns into a full GETA and ends up on CPB and is in the CTICU intubated on a ventilator. You have now taken up resources in time when we need them most.

Additionally, we are not positive that your patient doesn't have COVID (since we don't have wide spread testing available), you might have performed an emergency intubation and aerosolized COVID into the room with staff members who do not have PPE on.

 

[deleted171991]

everyone according to our cards guys

Incentive-based bias.

 

[anes121508]

Never masked before COVID. See no reason to start now.

As of now with limited testing and possible to be contagious without symptoms:

No MAC (can't guarantee 100% to non-protected staff in room you won't have to mask patient or emergently instrument the airway).

No LMA (seal isn't perfect)

 

[deleted171991]

As of now with limited testing and possible to be contagious without symptoms:

No MAC (can't guarantee 100% to non-protected staff in room you won't have to mask patient or emergently instrument the airway).

No LMA (seal isn't perfect)

I would rather LMA a difficult intubation (everybody should wear N95 and eye protection anyway) then get into trouble after paralysis, or play awake intubation (and cough). Also, the spontaneous ventilation won't create as many aerosols as the cough after ETT extubation.

 

[anes121508]

I would rather LMA a difficult intubation (everybody should wear N95 anyway) then get into trouble after paralysis, or play awake intubation (and cough). Also, the spontaneous ventilation won't create as many aerosols as the cough after ETT extubation.

Difficult airway is a major consideration.
Blanket statement of GETA and RSI all people is difficult to adhere to without increasing some risk to patient.

Known COVID w/difficult airway: I agree on LMA (if appropriate for case and clinical status) and everyone in room wearing N95 and full PPE

Unknown COVID without difficult airway: same

Extubation plan:
Known/suspected COVID: extubation in negative pressure room
Unknown COVID: extubation in OR with only anesthesia staff in room and PPE on

 

[anes121508]

I would rather LMA a difficult intubation (everybody should wear N95 and eye protection anyway) then get into trouble after paralysis, or play awake intubation (and cough). Also, the spontaneous ventilation won't create as many aerosols as the cough after ETT extubation.

On a side note, about aerosols and coughing...ID is telling us that coughing does not generate aerosols. Haven't researched it yet to be certain. Immediately after extubation vs a patient coming in just coughing is probably different. Any real insights here? Sources?

 

[deleted171991]

On a side note, about aerosols and coughing...ID is telling us that coughing does not generate aerosols. Haven't researched it yet to be certain. Immediately after extubation vs a patient coming in just coughing is probably different. Any real insights here? Sources?

It seems that breathing also generates aerosols. Awesome.

Study confirms flu likely spreads by aerosols, not just coughs, sneezes

www.cidrap.umn.edu

When the team analyzed the samples, they found that a significant number of patients routinely shed infectious virus—not just RNA particles—into particles small enough for airborne transmission. They were surprised to find that 11 (48%) of the 23 fine aerosol samples acquired when patients weren't coughing had detectable viral RNA, and of those 8 contained infectious virus, suggesting that coughing isn't a prerequisite for generating fine aerosol droplets.

In the few sneezes captured by the Gesundheit machine, investigators didn't see greater viral RNA copy numbers in coarse or fine aerosols, hinting that sneezing doesn't make as important a contribution as virus shed through aerosols.

P.S. Good ID people = priceless.

 

[deleted162650]

It seems that breathing also generates aerosols. Awesome.

Study confirms flu likely spreads by aerosols, not just coughs, sneezes

www.cidrap.umn.edu

P.S. Good ID people = priceless.

In related news, researchers have developed a Gesundheit Machine.

 

[vector2]

On a side note, about aerosols and coughing...ID is telling us that coughing does not generate aerosols. Haven't researched it yet to be certain. Immediately after extubation vs a patient coming in just coughing is probably different. Any real insights here? Sources?

Lol, what? Coughing absolutely generates aerosols

A Cough Aerosol Simulator for the Study of Disease Transmission by Human Cough-Generated Aerosols

Aerosol particles expelled during human coughs are a potential pathway for infectious disease transmission. However, the importance of airborne transmission is unclear for many diseases. To better understand the role of cough aerosol particles in the ...

www.ncbi.nlm.nih.gov

And even without the physics research, the very fact that airborne transmission of disease exists ipso facto means coughing generated aerosols also exist.

 

[deleted171991]

Lol, what? Coughing absolutely generates aerosols

A Cough Aerosol Simulator for the Study of Disease Transmission by Human Cough-Generated Aerosols

Aerosol particles expelled during human coughs are a potential pathway for infectious disease transmission. However, the importance of airborne transmission is unclear for many diseases. To better understand the role of cough aerosol particles in the ...

www.ncbi.nlm.nih.gov

Apparently not much more than breathing.

 

[abolt18]

Agree. Wish I could say that for all providers.

Devils advocate:
What happens when the TAVR , that could be done in 3-6 months, turns into a full GETA and ends up on CPB and is in the CTICU intubated on a ventilator. You have now taken up resources in time when we need them most.

Additionally, we are not positive that your patient doesn't have COVID (since we don't have wide spread testing available), you might have performed an emergency intubation and aerosolized COVID into the room with staff members who do not have PPE on.

I was definitely not sharing that in favor of doing the cases at this time, only saying that our TAVRs get almost nothing.

I have seen a fair share of TAVRs turn bad and do so quickly. I wouldn't risk it when we're short ventilators.

 

[kmurp]

So....we ordered a bunch of airway filters yesterday which, I believe, filter down to 0.3 microns. APSF and others recommend these. Now I’m reading that the virus is smaller than this at 0.12 microns. Anyone hav any clarity on this?