key: cord-256357-dlc8yb6j
authors: Augoustides, John G.
title: Cardiopulmonary Resuscitation during the Coronavirus Crisis – important updates for the cardiothoracic and vascular anesthesia community
date: 2020-04-28
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.04.039
sha: 
doc_id: 256357
cord_uid: dlc8yb6j

nan

The guidelines about cardiopulmonary life support have been updated in 2015 and more recently in 2019. [1] [2] [3] These recent revisions have addressed aspects such as airway strategies, vasopressor therapy, and the role of extracorporeal membrane oxygenation. [2] [3] [4] The coronavirus pandemic has since challenged critical care worldwide, prompting significant adjustments in the delivery of acute cardiopulmonary support at the point-of-care. [5] [6] These considerations have impacted the clinical approaches to both diagnosis and management of the acute cardiopulmonary presentations of coronavirus disease -2019 (COVID-19). [7] [8] In the event of cardiac arrest, the conduct of basic and advanced life support in adults, children and neonates requires thoughtful adaptations to address the challenges associated with COVID-19. 5 The perspectives from care providers in the frontlines have raised the following issues about life support for cardiac arrest during the COVID-19 pandemic: infection control, risk-stratification to guide decision-making, protocols to guide resuscitation in patients who wish to set limits on their care, and, further deliberations at the national level to inform point-of-care delivery in this context. 5 These perspectives and unique considerations in COVID-19 have resulted in a recent update to the guidelines for basic and advanced life support. [5] [6] These guideline updates have addressed the following major considerations in the conduct of life support in these challenging settings: provider exposure; oxygenation and ventilation strategies; the appropriateness of resuscitation; and, lastly considerations specific to 3 certain care situations. 6 The purpose of this freestanding editorial to outline these timely recommendations for life support in cardiac arrest. These perspectives can serve as a clinical update for the perioperative cardiothoracic and vascular community as we navigate the coronavirus pandemic at our respective institutions.

The spectrum of infection with COVID-19 includes risks of hospital admission and critical illness that have estimated to be in the (10-20)% and (5-10)% ranges respectively. [8] [9] The possible etiologies for cardiac arrest in COVID-19 include hypoxia from adult respiratory distress syndrome, cardiogenic shock from myopericarditis, and vasoplegic shock from associated sepsis. [8] [9] Furthermore, severe infection in COVID-19 can precipitate acute coronary syndromes and significant arrhythmias in patients with predisposing risk factors. [8] [9] The risk of arrhythmias may also be increased by proposed therapies for COVID-19 such as hydroxychloroquine and azithromycin through their prolongation of the QT interval. [9] [10] Given that there are multiple mechanisms for cardiac arrest in COVID-19, it is likely that there may be more than one mechanism in certain cases. Echocardiography at the bedside may be helpful to diagnose and manage the etiology of circulatory shock and should be conducted in accordance with the latest recommendations for COVID-19. [11] [12] [13] The clinical utility of bedside ultrasound should be remembered for serial evaluation of the presence and progression of pulmonary infection in COVID-19. 13

It is important that providers limit their risk for contracting COVID-19 to maintain their physical and psychological safety, and to minimize attrition of the workforce. [14] [15] The rescuers should utilize full recommended barrier precautions before entering the resuscitation area, including 4 correct application of personal protective equipment. [14] [15] [16] The rescuer team should follow the institutional protocol for infection control, given that the specific recommendations will depend on the current intensity of the pandemic and resource availability. 17 The expert consensus has also advised that personnel be limited to those who are essential for provision of clinical care and that the team employ clear and structured communication, including the details of COVID-19 status and plans to address infection control. [5] [6] Furthermore, where available and applicable, the rescuer team should also consider the deployment of mechanical devices for chest compressions in order to limit required providers for resuscitation in adolescents and adults. 6

The risk of viral aerosilization during airway management and consequent infection is considered high in the presence of COVID-19 infection. 17 The risks of viral aerosolization are greatly minimized in the setting of endotracheal intubation with a cuffed endotracheal tube and a closed circuit with in-line suction and a high-efficiency particulate air (HEPA) filter in the path of the exhaled gas flow. [17] [18] The value of viral clearance with a HEPA filter has justified the recommendations that positive pressure ventilation in life support be carried out with this device, whether by bag-and-mask, supraglottic airway device, or an endotracheal tube. 6 The preferred airway management in this setting is prompt endotracheal intubation with an experienced operator and videolaryngoscopy if available while chest compressions are paused. 6 The viral isolation in a closed circuit is also further enhanced with minimized disconnects. The detailed protocols for airway management in this setting have prompted the development and deployment of specialized airway teams at some institutions. [17] [18] 5 The intensity of the team effort in cardiopulmonary resuscitation can draw clinical attention from other patients in the same hospital area. 19 Furthermore, the mortality for critical care illness in COVID-19 is high, especially in the presence of major risk factors such as advanced age, diabetes, concomitant cardiovascular disease, and immunosuppression. [7] [8] [9] Resources can be scarce at times during the pandemic, especially at the peak of the crisis in certain regions. [19] [20] It is therefore important to consider the probability of success in cardiopulmonary resuscitation in a given case versus the risks of infection, diverted clinical attention and resource utilization during the pandemic, especially in stressed health care environments during the crisis phase of the COVID-19 crisis. 5-9; 19-20 Given these considerations, the expert consensus has recommended that goals of care be addressed with patients and their families, especially if escalations in care are deemed likely due to clinical trajectory and associated risk factors. [5] [6] The palliative care service can be a valuable resource to guide and inform these discussions. [21] [22] The institution should consider protocols to guide cardiopulmonary resuscitation for the workforce on the frontlines of care in the pandemic. [5] [6] These protocols should take into account input from all stakeholders as well as known risk factors for mortality. They can also be indexed to local conditions in real-time through the surge phases of the pandemic. [22] [23] [24] [25] These institutional recommendations should include indications and contraindications for extracorporeal membrane oxygenation in patients with severe COVID-19 in a fashion appropriate for expertise and resources at a given medical institution. 7-9; 26-28

In patients that are critically ill with COVID-19, the expert consensus has recommended that the goals of care be addressed with the decision-makers, especially if there is a significant change in 6 clinical status. [5] [6] These patients should be closely monitored and managed so that endotracheal intubation is conducted in an elective fashion, since airway management in an emergency setting carries higher risk for both patient and providers. [16] [17] [18] If possible, these patient should be managed in a negative pressure room behind closed doors to further minimize the risks of viral transmission. [16] [17] [18] In the setting of a patient with COVID-19 who has an endotracheal tube at the time of cardiac arrest, the closed circuit should be maintained with a HEPA filter. 6 The ventilator settings should then be titrated according to clinical response and the trend in arterial blood gases with attention to the inspired oxygen concentration, the tidal volume, the respiratory rate, and the levels of positive end-expiratory pressure. 6 The patient should be sedated as needed to prevent unplanned tracheal extubation. If the patient is prone at the time of cardiac arrest without a secure airway, the preferred management is to proceed to the supine position for prompt endotracheal intubation and continued cardiopulmonary resusicitation. [5] [6] If a prone patient with an endotracheal tube has a cardiac arrest, the supine position is preferred for cardiopulmonary resuscitation but only if the turn can be conducted safely. [5] [6] The associated cardiopulmonary changes of pregnancy may increase the risks of clinical deterioration in severe COVID-19. 5-10; 29 Preparations for perimortem delivery should begin very early in resuscitation, given the additional considerations, including infection conrol. [5] [6] In the setting of neonatal resuscitation, the providers should exercise all barrier protections in the event of suspected or known COPVID-19 for the child or mother. Since airway suctioning after delivery is high-risk for viral aerosilization, it is not indicated for uncomplicated deliveries. [5] [6] The intravenous rather than endotracheal administration of epinephrine has been advocated for 7 infection control. The transport and care of neonates who are critically ill with COVID-19 should be conducted in closed incubators to minimize viral transmission. 6

The current pandemic from COVID-19 has prompted multiple new priorities in cardiovascular life support. These priorities concern provider exposure, viral aerosolization, appropriateness of resuscitation and specific scenarios to balance both quality of care and infection control.

American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the Basic Life Support; Advanced Life Support

Neonatal Life Support; Education and Implementation; and First Aid Task Forces

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Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart

American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians

Extracorporeal membrane oxygenation -crucial considerations during the coronavirus crisis

Cardiovascular considerations and consequences of coronavirus infectionperspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis

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Chinese Association of Anesthesiologists expert consensus on the use of perioperative ultrasound in coronavirus 2019 patients

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Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019

Intensive care management of coronavirus disease (COVID-19): challenges and recommendations

Consensus guidelines for managing the airway in patients with COVID-19

Association between in-hospital critical illness events and outcomes in patients on the same ward

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Palliative care for patients with advanced heart disease

The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic

Maximizing the calm before the storm: tiered surgical response plan for the novel coronavirus (COVID-19)

Creating a palliative care inpatient response plan for COVID-19 -the UW Medicine experience

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Extracorporeal membrane oxygenation during adult noncardiac surgery and perioperative emergencies: a narrative review

Clinical management of venoarterial extracorporeal membrane oxygenation

Predictors of neurologic recovery in patients who undergo extracorporeal membrane oxygenation for refractory cardiac arrest

Cardiac interventions in pregnancy and peripartum -a narrative review of the literature