June 23/30, 2020 e933 Existing American Heart Association cardiopulmonary resuscitation (CPR) guidelines do not address the challenges of providing resuscitation in the setting of the coronavirus disease 2019 (COVID-19) global pandemic, wherein rescuers must continuously balance the immediate needs of the patients with their own safety. To address this gap, the American Heart Association, in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists, and with the support of the American Association of Critical Care Nurses and National Association of EMS Physicians, has compiled interim guidance to help rescuers treat individuals with cardiac arrest with suspected or confirmed COVID-19.Over the past 2 decades, there has been a steady improvement in survival after cardiac arrest occurring both inside and outside the hospital. 1 That success has relied on initiating proven resuscitation interventions such as high-quality chest compressions and defibrillation within seconds to minutes. The evolving and expanding outbreak of severe acute respiratory syndrome coronavirus 2 infections has created important challenges to such resuscitation efforts and requires potential modifications of established processes and practices. The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients. Complicating the emergency response to both out-of-hospital and in-hospital cardiac arrest is that COVID-19 is highly transmissible, particularly during resuscitation, and carries a high morbidity and mortality.Approximately 12% to 19% of COVID-positive patients require hospital admission, and 3% to 6% become critically ill. [2][3][4] Hypoxemic respiratory failure secondary to acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest, [5][6][7][8] as do some of the proposed treatments such as hydroxychloroquine and azithromycin, which can prolong the QT. 9 With infections currently growing exponentially in the United States and internationally, the percentage of patients with cardiac arrests and COVID-19 is likely to increase.Healthcare workers are already the highest-risk profession for contracting the disease. 10 This risk is compounded by worldwide shortages of personal protective equipment (PPE). Resuscitations carry added risk to healthcare workers for many reasons. First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway. During those procedures, viral particles can remain suspended in the air with a half-life of ≈1 hour and

Objective The contribution of bacterial co-infection to critical illness associated with 2009 influenza A (H1N1) [pH1N1] virus infection remains uncertain. The objective of this study was to determine if bacterial co-infection increased the morbidity and mortality of pH1N1. Design Retrospective and Prospective cohort study Setting 35 adult U.S. intensive care units over the course of one year Patients 683 critically ill adults with confirmed or probable pH1N1 Interventions None Measurements and Main Results A confirmed or probable case was defined as a positive pH1N1 test result or positive test for influenza A that was otherwise not subtyped. Bacterial co-infection was defined as documented bacteremia or any presumed bacterial pneumonia with or without positive respiratory tract culture within 72 hours of ICU admission. The mean age was 45±16 years, mean BMI 32.5±11.1 kg/m2, and mean APACHE II score 21±9, with 76% having at least one co-morbidity. Of 207 (30.3%) patients with bacterial co-infection on ICU admission, 154 had positive cultures with Staphylococcus aureus (n=57) and Streptococcus pneumoniae (n=19) the most commonly identified pathogens. Bacterial co-infected patients were more likely to present with shock (21 vs. 10%; P=0.0001), require mechanical ventilation at the time of ICU admission (63 vs. 52%; P=0.005) and have longer duration of ICU care (median 7 vs. 6 days; P=0.05). Hospital mortality was 23%; 31% in bacterial co-infected patients and 21% in patients without co-infection (P=0.002). Immunosuppression (RR 1.57; 95% CI 1.20–2.06; P=0.0009) and Staphylococcus aureus at admission (RR 2.82; 95% CI: 1.76–4.51; P<0.0001) were independently associated with increased mortality. Conclusions Among ICU patients with pH1N1, bacterial co-infection diagnosed within 72 hours of admission, especially with Staphylococcus aureus, was associated with significantly higher morbidity and mortality.

In the context of reducing risk of nosocomial bloodstream infections, failing to provide > or =25% of the recommended calories may be harmful. Higher caloric goals may be necessary to achieve other clinically important outcomes.