key: cord-0768007-10tvepa5 authors: Yang, Manping; Dong, Hailong; Lu, Zhihong title: Role of anaesthesiologists during the coronavirus disease 2019 outbreak in China date: 2020-04-09 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.03.022 sha: 3f7e9daaeb97315de63de79252cb9449586e25e3 doc_id: 768007 cord_uid: 10tvepa5 nan of initial symptoms the infection rapidly aggravated and extended to a bilateral multi-lobar pulmonary effusion and consolidation. Although non-invasive ventilation temporarily improves oxygenation in COVID-19 patients, it may not necessarily change the natural course of the acute respiratory distress syndrome (ARDS). 3 On 18 February 2020, the state council of China issued Question and answers of tracheal intubation for novel coronavirus pneumonia cases, in which the criteria for tracheal intubation were defined as oxygenation index < 150 mmHg after at least 2 h of continuous positive airway pressure (CPAP) with 100% oxygen, and it was recommended that intubation be scheduled rather than emergent. According to the new criteria, patients would receive intubation and ventilation therapy earlier. As a result, more patients needed intubation. In many hospitals, airway management teams consisting of skilled anaesthesiologists were established to meet the need for intubation. Depending on the anaesthesiologists available, airway management team size was [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] people. Airway management team members worked in rotation, with only 1-2 anaesthesiologists in the isolation ward at a time. The minimal size helps avoid unnecessary viral exposure. An intubation cart containing modular packs of medicines and materials was kept in the ward to minimise the traffic of people bringing materials into the room. Videolaryngoscopy with a replaceable blade was widely used to avoid placing the face of the anaesthesiologist close to the patient. Light wand, laryngeal mask airway (LMA), flexible bronchoscope and cricothyroid puncture kit were also available in the cart in case of difficult intubation. Protocols for unanticipated difficult airway were followed, highlighting the role of an intubating LMA. 4 Any known or suspected COVID-19 patient must be regarded as ultra-high risk. Tracheal intubation of these patients is a high-risk aerosol-generating airway procedure requiring standard grade 3 personal protective equipment (PPE) 4 3 February, 2020. 4 According to these recommendations and current evidence, principles include minimizing generation of aerosols (see Supplemental Digital Content 1 for guidance for tracheal intubation of COVID-19 cases). 4 5 Bag-mask ventilation prior to intubation, patient coughing during laryngoscopy or intubation, and inadequate sedation putting the patient at risk of agitation can generate aerosols. With adequate pre-oxygenation, bag-mask ventilation can ideally be avoided. Continuous positive airway pressure (CPAP) with 100% oxygen for 5 min is recommended for pre-oxygenation. If available, high-flow nasal cannula (HFNC) delivery systems can be used for pre-oxygenation, though these can increase the risk of viral spread through aerosol generation. 6 To minimise this risk, the mouth and nose of the patient can be covered with normal saline saturated gauze during pre-oxygenation. To avoid agitation and cough, intubations are best done using a rapid sequence intubation technique. 4 5 Midazolam, propofol and etomidate can be used depending on the patient condition. After sedation, at least 0.9 mg kg -1 of rocuronium or 1 mg kg -1 of succinylcholine should be used. A hydrophobic filter should be attached to the resuscitation bag, between the mask or tracheal tube (TT) and the bag. When difficult airway is anticipated, flexible bronchoscopic intubation can be performed using a videobronchoscope. Awake fibreoptic intubation should be avoided to decrease exposure to aerosols. 5 If unanticipated difficult airway occurs, anintubating LMA and surgical airway can be considered. Extubation with minimal agitation and coughing is important for both ICU patients and surgical patients. Careful suctioning with a closed sputum suction device before return of consciousness can be important. 7 A recent meta-analysis 8 reported that procedures (including dexmedetomidine, remifentanil, fentanyl, and lidocaine i.v., intracuff, tracheal or topical) were all better than placebo in reducing moderate to severe emergence cough, with dexmedetomidine ranked the most effective. Dexmedetomidine and lidocaine by various routes have been used in COVID-19 cases. Extubation before return of consciousness is recommended for patients without a difficult airway. 7 However, a device for reintubation should be available. Extubation without removal of the filter is important. 4 Anaesthesiologists in surgical intensive care units (SICU) and anaesthesia intensive care units (AICU) contribute greatly to the management of COVID-19 cases. At Jinyintan Hospital in Wuhan, 9 of 17 patients who developed ARDS, 11 worsened in a short period of time. At Zhongnan Hospital in Wuhan, 10 47.2% of patients in the ICU received invasive ventilation and four were switched to extracorporeal membrane oxygenation (ECMO). Preprint reports of deaths revealed that durations from initial symptoms to death were short (15 days, interquartile range 11-20 days). 11 Autopsy results of COVID-19 cases indicated much sticky mucus in the small airways. 12 A high percentage of patients in the ICU need 'active' invasive airway intervention, and critically ill patients may benefit from ECMO, two fields that anaesthesiologists are expert in. During the outbreak, critical care services in China were confronted with a rapid increase in the demand on resources. All hospitals and other organizations were involved in the care for COVID-19 cases. In many hospitals airway team members took charge of ventilation management after tracheal intubation. Once intubated, classical ventilation strategies 6 13 Epidemiological links include travel within 14 days to affected areas, or close contact within 14 days of illness onset with a confirmed patient, or close contact with a person having fever and respiratory symptoms and travel to an affected area within 14 days of illness onset. 13 Fever may not be present in all patients. The absence of fever in COVID-19 is more frequent than in SARS and MERS, so appropriate infectious control precautions should be in place even in those without typical symptoms. 16 With the spread of the virus to more areas and countries, anaesthesiologists all over the world may face the challenge of weighing the risk of infection and the need for medical care of patients. Chinese academic anaesthesiology organizations immediately reacted to the COVID-19 outbreak, focusing on improving medical care and protecting anaesthesiologists. WHO: Coronavirus disease (COVID-2019) situation report-55 Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia Access published February Respiratory support for patients with COVID-19 infection Expert Recommendations for Tracheal Intubation in Critically ill Patients with Novel Coronavirus Disease Outbreak of a new coronavirus: what anaesthetists should know Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Chinese Society of Anesthesiology. 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Protocol of diagnosis and treatment of novel coronavirus cases Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment Ultrasound-guided lung sliding sign to confirm optimal depth of tracheal tube insertion in young children Clinical Characteristics of Coronavirus Disease 2019 in China The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk Platform for questions and answers during novel coronavirus outbreak The reproductive number of COVID-19 is higher compared to SARS coronavirus World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) Pulmonary Pathology of Early Phase SARS-COV-2 Pneumonia Access published March Pathological findings of COVID-19 associated with acute respiratory distress syndrome COVID-19): A Perspective from China