This report summarizes key points and topics from web conferences from the past two days in physicians’ COVID-19 Facebook groups, and incorporates relevant updates from literature and official updates.
The report is divided into the following subjects:
- General – relevant links and updated treatments and studies
- General tips
1.1 Relevant Links
- The Chinese First Affiliated Hospital, School of Medicine, Zhejiang University, one of the main hospitals that treated the COVID-19 patients, has published a handbook of COVID-19 prevention and treatment. This handbook includes in an accessible and clear way many protocols and guidelines that were used during the treatment of the virus, including measures taken for prevention and control management, diagnosis, treatment, and nursing.
- Anesthesiology, ICU, and radiology specialists from over 450 medical centers prepared a Google Drive folder, containing information in English regarding airway management, guidelines during surgical treatment, managing patients in the ICU, OR preparation, and more. The information is being updated on a daily basis.
- Here you can find a pocket-protocol for mechanical ventilation made by the ARDSnet.
- Emergency Medicine Practice has published an updated overview for emergency clinicians, analyzing the information from the early research, including epidemiology, pathophysiology, virology, prevention diagnosis, and treatment of COVID-19 patients. Furthermore, they have included helpful tips on imaging analysis and lessons learned from the experience of an emergency physician in Northern Italy.
- Doctors from Spain, Italy, USA, and China call out to all physicians who don’t practice basic ICU treatment in their everyday work to go over and practice the basic principles of basic critical care since each physician will have to take part in the treatment of COVID-19 patients. Following you will find relevant links for staff members:
1.2 – Treatment Updates
- Treatment with NSAIDs in COVID-19 patients- the European Medicines Agency (EMA) has stated that there is currently no scientific evidence establishing a link between Ibuprofen and worsening of COVID-19, following the FDA’s and WHO’s earlier statements. The agency has added that when starting treatment for fever or pain in COVID-19, patients and healthcare professionals should consider all available treatment options, including Paracetamol and NSAIDs. Each medicine has its own benefits and risks, which are reflected in its product information.
- The Ministry of Health in Singapore has published updated reviews that include clinical evidence summaries and treatments in use for COVID-19 patients. For instance, a review of Tocilizumab. Other reviews can be found in the link.
- The Mount Sinai Health System in New York has initiated a plasmapheresis program in which critically ill patients will receive antibodies from patients who have recovered from COVID-19.
- In Germany, a new phase 3 study is expected to begin, examining the efficacy of the vaccine candidate VPM1002 (BCG, against tuberculosis) for COVID-19 patients. The study is to be carried out at several hospitals in Germany and will include older people and health care workers. Animal studies demonstrated a lower viral load of influenza A in mice who had previously been vaccinated with BCG. The vaccine is currently being tested in another phase III study on healthy adult volunteers in India.
2. General tips
- The Department of Anesthesiology at the University of Florida has developed masks that can be produced using common materials in hospitals and medical facilities. Masks are created from the sterile wrapping that is normally used to wrap surgical instrument trays before they pass through gas sterilization or an autoclave. The mask is a little more efficient than the N95 masks, according to the manufacturer’s specifications. Approximately 10 masks can be prepared from one sheet of Halyard material. The production process includes sending the material to a seamstress, and upon return, the masks are sterilized by UV light or autoclave before being distributed to health care providers. A mask tutorial can be found here.
- Intubation and ventilation via BiPAP machine as a temporary substitution of mechanical ventilation in COVID-19 patients– as there is expected to be a shortage of ventilation machines, there is an option of using a BiPAP machine following intubation in the ER, in case of no available standard mechanical ventilation device. It should be noted that the use of NIPPV should be avoided due to aerosol generation. This link contains detailed information, including algorithms, guidelines, and tutorials on the topic. (Written by Keith Robinson, MD, MS, FCCP; Peter Polos, MD, Ph.D., FCCP, FAASM; Jeffrey J. Stewart, MA)
- Aerosol exposure reduction cover for intubation (St. Louis, USA) – the cover shown in the image is draped over the patient. Inside the cover, there are 3 ports – two near the patient’s head and one above the chest, allowing unrestricted access to the patient during intubation. Detailed instructions in English on how to prepare the cover can be found in this link. These doctors initially started using the “aerosol box” (which we reported on in the previous report), but due to logistical difficulties (heavy box, limited hand movement, multiple-use, unsuitable for various body shapes), they decided to develop a different kind of protection device.
- Another guide on how to externalize monitors and IV pumps out of the patient’s room to save PPE and reduce staff exposure.
- SAGES official guidelines- following the official guidelines published on March 19, the organization released an update regarding its declaration on the potential viral transmission during laparoscopic surgeries. The organization stated that, as of today, there is no evidence to indicate the presence of SARS-CoV-2 aerosols during abdominal surgeries and that the available data is of other viruses. The organization emphasizes that despite the lack of information, caution should be exercised.
- Intubation in operating rooms and prevention of staff exposure– there are reports from several US hospitals (such as Oregon Health & Science University) of new guidelines for operating room staff:
- The surgical team was instructed to wait 20 minutes between intubation and entering the OR. Within 20 minutes, the ventilation system in these operating rooms replaces all the air in the room. After extubation, wait another 20 minutes before re-entry.
- During intubation, only anesthesiologists are allowed to be in the OR (regardless of whether the patient is suspected, confirmed, or asymptomatic COVID-19).
- In cases of urgent surgeries– the operating room staff must have full PPE during intubation.
- At the end of the operation- surgeons should leave the OR for the extubation, and wait outside in case of an emergency, with available PPE nearby.
- Covering the upper body part of the patient to reduce the spread of aerosols is recommended.
- We emphasize that in the previous report, one of the hospitals suggested the option of intubating in a negative pressure room and then transfer the patient to the OR, thus preventing the operating room staff exposure to the aerosol.
- Laparoscopic surgeries during the pandemic– in this link, you can find guidelines, an algorithm for Minimally Invasive Surgery, a patient questionnaire before surgery, and more. The files were shared by Carolinas Medical Center in North Carolina, USA.
- A useful database for surgeons– includes recommendations for surgical procedures, guidelines, ventilator management, intensive care guides, and more.
The American College of Radiology has published new guidelines regarding the use of imaging during the SARS-CoV-2 virus outbreak:
- CT should not be used for screening for or as a first-line test to diagnose COVID-19.
- CT should be reserved for hospitalized, symptomatic patients with specific clinical indications.
- Measures should be taken to decontaminate the CT device.
- CXR– deploying portable radiography units should be considered, since these machines can be easily cleaned, avoiding the need to bring patients into radiography rooms.
- Radiologists should learn to recognize the CT appearance of COVID-19 infection in order to be able to identify findings consistent with infection in patients imaged for other reasons.
- Isolation or treatment should not be decided solely based on a CT finding. These findings are not specific for COVID-19, and viral testing remains the only specific method of diagnosis.
Dermatologists from Sun-Yat sen University Hospital in China report on their experience in dealing with COVID-19:
- They state that epidemiologic history and respiratory symptoms should be examined in any patient who is presenting with fever along with cutaneous lesions.
- They report that the increased use of conventional as well as unconventional drugs has led to an increase in cases of pruritus and allergic reactions to drugs.
- They found that in COVID-19 patients, there is often an aggravation of previous skin disease. They point out the emotional stress during the outbreak as a possible cause.
- They claim that the use of protective masks and disinfectants may cause skin irritation in both COVID-19 patients and healthy people.
- They note that patients with several cutaneous diseases are at greater risk of developing cardiovascular disease, depression, and other health conditions, which makes them more vulnerable to the virus.
They recommend considering the use of IL-17 inhibitors, that quickly function to control the skin lesions and have lower effects on personal immune functions, and avoiding traditional immunosuppressive drugs.
Colorectal surgeons from Italy and Spain have published an article describing the expected outcomes of the pandemic on the treatment of cancer patients:
- The ideal time of resection is estimated to be between 3 and 6 weeks from diagnosis, which is unlikely to be achieved these days, and the long-term effects on the quality of care can only be assumed.
- Priorities and standards of care need to be reassessed.
- Possible measures include alternative treatment to radical surgery in very early-stage cancer or very advanced disease and centralization of patients in need of postoperative stays in ICUs in few tertiary care hospitals.
7. Intensive care / Pulmonology
- In a joint statement by anesthesia, pulmonology, and intensive care organizations, it was advised for clinicians not to use a single ventilator for multiple patients. In case of a shortage in ventilators, they recommend ventilating patients who are likely to benefit. More details in the attached link.
- An interview with Dr. Michelle N. Gong, epidemiologist, researcher, and Chief of Critical Care Medicine at Montefiore Medical Center in New York. The interview was part of a series of interviews with doctors, conducted by JAMA during the pandemic. Key points from the interview:
- Doctors knew in advance that COVID-19 patients would present with ARDS, and yet the course of the disease surprised them, and they needed to make adjustments as COVID-19 is not a classic ARDS.
- She recommends proning as early as possible and says that once you supinate these patients, they deteriorate very quickly. She said that there are patients in ICU who are in a proning position for 14-16 hours a day, and that certainly helps them.
- She describes patients who have been extubated, seemed stable, and then rapidly developed hypoxemia and required re-intubation.
- The course of the disease- patients can appear completely stable at the onset of the disease, and on days 5-7, respiratory failure begins to develop, which can happen rapidly (she described it as a “respiratory arrest”).
- She warns against the uncontrolled use of unapproved drugs and emphasizes that physicians should look out for side effects in order to avoid harm.
- Cardiovascular complications– they see many cases of acute MI and myocarditis. Gong also reports many cases of elevated troponin, poor cardiac function, and arrhythmias. It is not clear yet whether this is part of the manifestation of the systemic disease itself or a different representation of the disease.
- Young patients Involvement– she says that they also see young patients (ages 20-30) in the ICU with ARDS, but still notes that most patients in the unit are very old and have comorbidities.
- Staff management– she praised the anesthesia teams and their unique capabilities in respiratory distress management. Now that these teams are available since there are no elective surgeries, their skills should be utilized.
- The guidelines for noninvasive ventilation in COVID-19 patients were described. She emphasizes that the risk in NIV is the generation of aerosols, and on the other hand, the risk of intubation should be considered. Her recommendations:
- In patients with hypoxic respiratory failure and ARDS, it is recommended to try HFNC as it seems to reduce the rate of intubation later.
- BPAP has not been shown to lower intubation rates in ARDS patients.
- In patients who do not require urgent intubation- a trial of HFNC is recommended.
- In a telephone interview, a couple of pediatric intensive care physicians who are now treating adult patients with COVID-19 in Italy, describe a scoring system they use to assess patients who require intubation. The scoring system includes:
- Background illnesses
- Ventilation technique
- P/F ratio
The higher the score, the greater the need for intubation. The system is also used for triage and assessing the patient’s progress. They point out that this is a way in which non-ICU doctors can quickly evaluate patients and decide whether it is required to involve experts in the field.
- International pulmonology experts have gathered the latest guidelines on patient management, therapeutic options, prognostic factors, and more, in the International Pulmonologist’s Consensus COVID-19 Booklet. Link to the file in the drive.
- A useful and up-to-date presentation prepared by Arun Jose, a pulmonology/critical care expert in Cincinnati, Ohio. The presentation summarizes the guidelines and considerations for diagnosis, treatment, and management of COVID-19 patients with an emphasis on pulmonology and ICU. Link to the file in the drive.
Cardiologists in Italy have published a review on aspects of management and care of patients with cardiovascular disease in light of changes in the health system in Italy during the pandemic. Following are the key points:
- Prioritization of unstable patients with cardiovascular disorders– the paper describes which treatments were postponed and according to which criteria patients were prioritized.
- Reorganization of work– cardiologists in hospitals were divided into two teams: the first took part in cardiovascular emergencies, and the second focused on the management of COVID-19 patients with cardiovascular manifestations, including myocardial involvement.
- Patients with MI– their purpose was not to comprise the standard of care. The health system was reorganized so that patients were referred for catheterization in designated hospitals according to geographic proximity. The goal was to concentrate as many MI patients as possible in a limited number of hospitals.
- A case report of a 19-day-old neonate who was infected with COVID-19 in the city of Wuhan highlights the fact that infants often present with atypical symptoms, which include vomiting and refusal to eat. This fact makes the diagnosis of children and infants difficult. Also, this case describes improvement in the neonate’s condition within two weeks.
- The Journal of the American Medical Association describes a case in which a COVID-19 patient gave birth to an infant with positive IgM-SARS-CoV-2 antibodies. Following are the key point:
- Mother’s nasopharyngeal swab was SARS-CoV-2 positive; her breast milk and vaginal swab were negative.
- The neonate was born by cesarean delivery in a negative-pressure room; the mother wore an N95 mask and did not hold the infant.
- The neonate had no symptoms, CT was normal, and PCR tests for the virus were negative. Elevated cytokine levels were described (IL-6, IL-10).
- IgM antibodies are not transmitted through the placenta, and they usually do not appear until 3 to 7 days after infection. The elevated IgM antibody level suggests that the neonate was infected in utero.
A new international database Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) has been established for physicians treating COVID-19 IBD patients (adults and children) to monitor and report the outcomes of COVID-19 in these patients. Reporting a case takes approximately 5 minutes.
Following gastroenterologists, rheumatologists have also established an international registry to collect information on rheumatology patients with COVID-19. An example of the type of information collected, a direct reference to the registry in RedCap.
New labor and delivery guidelines were published in AJOG MFM. The first sections are relevant to childbirth for all women during the pandemic, part 6 describes special care for the COVID-19 positive or suspected pregnant women, and part 7 describes the management of the COVID-19 positive/suspected women who are critically ill.
Key points from the guidelines (please read the guidelines carefully as it contains specific instructions regarding the use of tocolytics, steroids, c/s which are not summarized here on tocolytics, and cesarean sections not summarized here):
- All medical teams are required to wear PPE until COVID-19 is ruled out. Full PPE includes a surgical mask, protective eyewear, gown, and gloves. The N95 mask is reserved for positive or suspected COVID-19 cases only.
- In the case of COVID-19 positive patients who are scheduled for cesarean or induction of labor, with COVID-19 mild or moderate symptoms not requiring immediate care, it is important to recognize that the severity of disease peaks in the second week, so planning delivery prior to that time is optimal.
- Visitation should be limited to one support person, in-person. Switching of visitors is not permitted.
- Parents may visit in the neonatal ICU- one at a time.
- In the current setting, where reducing the risk of COVID-19 spread among healthcare providers and patients is paramount, it is highly reasonable not to utilize oxygen therapy for fetal resuscitation. Given the likely high rate of asymptomatic carriers, this principle applies regardless of the patient’s COVID-19 status.