key: cord-0732823-k28gf7sd authors: Mehta, Christopher K.; Malaisrie, S. Chris; Budd, Ashley N.; Okita, Yutaka; Matsuda, Hitoshi; Fleischman, Fernando; Ueda, Yuichi; Bavaria, Joseph E.; Moon, Marc R. title: Triage and management of aortic emergencies during the coronavirus disease 2019 (COVID-19) pandemic: A consensus document supported by the American Association for Thoracic Surgery (AATS) and Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) date: 2020-10-30 journal: J Thorac Cardiovasc Surg DOI: 10.1016/j.jtcvs.2020.06.004 sha: ff772fede954c06b9dc2679e92c3277cf87afdf5 doc_id: 732823 cord_uid: k28gf7sd nan The coronavirus disease 2019 (COVID-19) pandemic has placed an unprecedented strain on hospitals worldwide, necessitating health care systems to triage patient care and redirect resources including personnel, equipment, and operating rooms. Aortic emergencies, including aortic dissection, rupture, and malperfusion syndromes, are resource-intensive and therefore can overwhelm a system already operating at maximal capacity. Although health care systems are necessarily shifting resources to address the COVID-19 pandemic, a contingency plan to continue to support aortic emergencies needs to remain in place. This document is meant to facilitate triage and management of these acute patients based on the best-available evidence. 1. How should hospitals manage COVID-19-positive or status unknown patients who present to their hospital with an aortic emergency? a. Patients who present to an emergency department (ED) with an aortic emergency should initially be triaged into 1 of 3 categories based on their COVID-19 status by testing. A flowchart for triaging patients is demonstrated in Figure 1 . i. COVID-19-negative: Patients who have tested negative for COVID-19 should be managed by transfer to a routine surgical operating room (OR) and routine surgical intensive care unit (ICU) postoperatively. 1. Patients who test negative but have concerning signs/symptoms and/or radiologic findings concerning for infection on computed tomography scan (ie, possible false-negative; see Figure 2 ) Bilateral ground-glass opacities and "crazy paving" in a patient infected with COVID-19. An algorithmic approach to acute aortic emergencies during the COVID-19 pandemic can reduce the risk of exposure for patients and health care providers. FIGURE 1 . Algorithm for triaging patients from the emergency room based on COVID testing status. *Patients requiring high flow oxygen, non-invasive ventilation, or other oxygen source with high potential for aerosol-generation should be considered for early intubation in the ER in order to reduce viral spread during transport. ED, Emergency department; COVID-19, coronavirus disease 2019; CT, computed tomography; PPE, personal protective equipment; OR, operating room; NP, nasopharyngeal; BAL, bronchoalveolar lavage; ICU, intensive care unit. with the Society of Critical Care Medicine recommendations. 1 3. Patients should be taken to a COVID-19designated ICU postoperatively until testing returns. If testing is negative, the patient should be transferred to a routine surgical ICU. 2. How should hospitals manage interfacility transfers of COVID-19-positive or status unknown patients? a. The transfer of care to a greater level of care centers capable of handling aortic emergencies should continue during the COVID-19 pandemic but is necessarily dictated by local protocols. A flowchart for triaging patients from an external hospital is provided in Figure 3 . i. Video laryngoscope allows the provider's face to be further away from the patient during intubation. 7 In addition, a video laryngoscope may be beneficial in decreasing failed intubation attempts 8 and increasing the success rate. ii. The use of a high-efficiency hydrophobic filter should be interposed between the endotracheal tube and resuscitation bag or anesthesia circuit. iii. Care should be taken to avoid contamination or cross-contamination after intubation. d. If testing for COVID- 19 was not yet achieved, a sample should be collected once in the OR. i. The nasopharyngeal swab may be obtained; however, concerns have been expressed over the sensitivity of this sample. 9 When the patient is intubated in the OR, a lower respiratory tract sample should be considered, in the form of a tracheal aspirate or bronchial alveolar lavage, in accordance with recommendations from the Society of Critical Care Medicine. 1 e. Ventilation of patients during the procedure should consider the pulmonary effects of patients infected with COVID-19. i. Infected patients may present with acute respiratory distress syndrome (ARDS); however, some patients may have mild hypoxemia or be asymptomatic carriers. 1. Low tidal volume mechanical ventilation should be used to prevent further lung injury, as indicated in other types of ARDS. 10,11 2. It is also reasonable to consider higher positive end-expiratory pressure as needed for hypoxemia per evidence-based ARDS protocols. 10,12 f. The risk of performing an intraoperative transesophageal echocardiogram (TEE) in patients infected with COVID-19 is high. i. Per the American Society of Echocardiography, the benefit of performing a TEE may outweigh the risk in a type A dissection in a COVID-19-positive or suspected patient. 13 A case-by-case basis should be considered when determining whether to perform a TEE. ii. Care should be taken to minimize contamination of surfaces while performing a TEE and appropriate PPE donned during the procedure. 5. What precautions should be taken by surgical personnel during the procedure? a. Expeditious repairs requiring minimal operating and cardiopulmonary bypass times should be favored over complex operations. The priorities should be to safely address any life-threatening issues, to be efficient with resource use, and to minimize the risk of postoperative complications. 14 i. Endovascular options (if available and applicable to the clinical scenario) should be considered over open surgical procedures when possible. b. Prepping and draping the patient should be done in usual sterile fashion, with emphasis on providing an appropriate drape barrier between anesthesia and surgical teams to minimize surgical personnel exposure to airway and TEE interventions. c. Observing, nonessential personnel should not be present during the procedure to reduce the amount of personnel in close contact. d. During the COVID-19 pandemic, there have been concerns over adequate blood supply for patients in some regions due to increased blood product use and blood donation shortages. Blood-conservation management should be used during surgical iii. acute normovolemic hemodilution 17 ; iv. viscoelastography-guided transfusions 18 ; and v. ensuring good hemostasis to minimize blood product use and need to return to OR. e. Chest tubes should be checked for air leaks and ensuring that all connections are secure to reduce exposure via contamination. 19 6. What are the postoperative considerations for COVID-19-positive and status-unknown patients? a. Patients should ideally be transported to a COVID-19-designated ICU with close consultation with the surgical team, unless hospital protocols dictate otherwise. b. Timing and planning for extubation will be multifactorial, and attention should be given to the patient's hemodynamic stability, neurologic examination, respiratory status, and any postsurgical concerns. i. Since extubation is also an aerosol-generating procedure, extubation should be performed in a negative-pressure airflow room with appropriate PPE and minimizing personnel in the room at time of extubation. ii. Meticulous care should be given to ensure patients are adequately ready for extubation to minimize risk of reintubation. c. Patients in whom COVID-status was initially unknown but later returns as negative should be moved to a routine surgical ICU setting. Dr Malaisrie: Terumo, Cryolife, and Medtronic; Dr Fleischmnan: Terumo, Edwards Lifesciences, W. L. Gore, and Cook; Dr Bavaria: Terumo, W. L. Gore, Medtronic, and Cook Vascular; Dr Moon: Medtronic. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. 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COVID-19: Chest Drains With Air Leak-The Silent 'Super Spreader'? Triage and management of aortic emergencies during the coronavirus disease 2019 (COVID-19) pandemic: A consensus document supported by the American Association for Thoracic Surgery (AATS) and Asian Society for Cardiovascular and Thoracic Surgery An algorithmic approach to acute aortic emergencies during the COVID-19 pandemic can reduce the risk of exposure for patients and health care providers.