Recommendations on cardiopulmonary resuscitation strategy and procedure for novel coronavirus pneumonia

Song, Wenjing; Liu, Yuanshui; Ouyang, Yan‐Qiong; Chen, Wenteng; Li, Min; Xianyu, Shuming; Yi, Shengyang

doi:10.1016/j.resuscitation.2020.03.023

Cited by 17 publications

(24 citation statements)

References 10 publications

(1 reference statement)

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“…Coupled with the highintensity nature of resuscitation care and risks to rescuers, the appropriateness of performing CPR on patients with COVID-19 has been debated (34)(35)(36). None of the institutions surveyed in this study were prohibiting CPR or instituting specific time limits on resuscitation duration as has been advocated by some groups (36). In fact, the majority (59%) do not have a specific policy, although 32% reported guidance to avoid prolonged CPR after reasonably addressing reversible causes of cardiac arrest.…”

Section: Discussionmentioning

confidence: 96%

“…The extraordinary circumstances of the COVID-19 pandemic have triggered discussion regarding the rationing of resources and the limitation of potentially futile therapies for particular populations of patients (33). Coupled with the highintensity nature of resuscitation care and risks to rescuers, the appropriateness of performing CPR on patients with COVID-19 has been debated (34)(35)(36). None of the institutions surveyed in this study were prohibiting CPR or instituting specific time limits on resuscitation duration as has been advocated by some groups (36).…”

Section: Discussionmentioning

confidence: 99%

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Pediatric Resuscitation Practices During the Coronavirus Disease 2019 Pandemic

Morgan

Kienzle

Sen

et al. 2020

Pediatric Critical Care Medicine

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Objectives: While most pediatric coronavirus disease 2019 cases are not life threatening, some children have severe disease requiring emergent resuscitative interventions. Resuscitation events present risks to healthcare provider safety and the potential for compromised patient care. Current resuscitation practices and policies for children with suspected/confirmed coronavirus disease 2019 are unknown. Design: Multi-institutional survey regarding inpatient resuscitation practices during the coronavirus disease 2019 pandemic. Setting: Internet-based survey. Subjects: U.S. PICU representatives (one per institution) involved in resuscitation system planning and oversight. Interventions: None. Measurements and Main Results: Of 130 institutions surveyed, 78 (60%) responded. Forty-eight centers (62%) had admitted coronavirus disease 2019 patients; 26 (33%) reported code team activation for patients with suspected/confirmed coronavirus disease 2019. Sixty-seven respondents (86%) implemented changes to inpatient emergency response systems. The most common changes were as follows: limited number of personnel entering patient rooms (75; 96%), limited resident involvement (71; 91%), and new or refined team roles (74; 95%). New or adapted technology is being used for coronavirus disease 2019 resuscitations in 58 centers (74%). Most institutions (57; 73%) are using enhanced personal protective equipment for all coronavirus disease 2019 resuscitation events; 18 (23%) have personal protective equipment policies dependent on the performance of aerosol generating procedures. Due to coronavirus disease 2019, most respondents are intubating earlier during cardiopulmonary resuscitation (56; 72%), utilizing video laryngoscopy (67; 86%), pausing chest compressions during laryngoscopy (56; 72%), and leaving patients connected to the ventilator during cardiopulmonary resuscitation (56; 72%). Responses were varied regarding airway personnel, prone cardiopulmonary resuscitation, ventilation strategy during cardiopulmonary resuscitation without an airway in place, and extracorporeal cardiopulmonary resuscitation. Most institutions (46; 59%) do not have policies regarding limitations of resuscitation efforts in coronavirus disease 2019 patients. Conclusions: Most U.S. pediatric institutions rapidly adapted their resuscitation systems and practices in response to the coronavirus disease 2019 pandemic. Changes were commonly related to team members and roles, personal protective equipment, and airway and breathing management, reflecting attempts to balance quality resuscitation with healthcare provider safety.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Pediatric Resuscitation Practices During the Coronavirus Disease 2019 Pandemic

Morgan

Kienzle

Sen

et al. 2020

Pediatric Critical Care Medicine

View full text Add to dashboard Cite

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“…Should intubation be required, several guidelines recommend the use of video laryngoscopy over direct laryngoscopy to allow further distance between the provider and patient [15,45,47,48,49]. The placement of a clear drape/tarp or box has been suggested to limit viral aerosolization; however, it is unclear how this influences first pass success [50].…”

Section: Endotracheal Intubationmentioning

confidence: 99%

“…Other studies evaluating their efficacy concluded they should not be used outside the operating room or in situations where a surgical airway may be needed [52,53]. Similar to the placement of an SGA, the most experienced healthcare provider should perform the intubation procedure [15,19,20,28,49]. The AHA recommends that chest compressions should be paused during intubation to reduce risk of disease transmission and to ensure first-pass intubation success [15].…”

Section: Endotracheal Intubationmentioning

confidence: 99%

COVID-19 cardiac arrest management: A review for emergency clinicians

Ramzy

Montrief

Gottlieb

et al. 2020

The American Journal of Emergency Medicine

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Introduction A great deal of literature has recently discussed the evaluation and management of the coronavirus disease of 2019 (COVID-19) patient in the emergency department (ED) setting, but there remains a dearth of literature providing guidance on cardiac arrest management in this population. Objective This narrative review outlines the underlying pathophysiology of patients with COVID-19 and discusses approaches to cardiac arrest management in the ED based on the current literature as well as extrapolations from experience with other pathogens. Discussion Patients with COVID-19 may experience cardiovascular manifestations that place them at risk for acute myocardial injury, arrhythmias, and cardiac arrest. The mortality for these critically ill patients is high and increases with age and comorbidities. While providing resuscitative interventions to and performing procedures on these patients, healthcare providers must adhere to strict infection control measures and prioritize their own safety through the appropriate use of personal protective equipment. A novel approach must be implemented in combination with national guidelines. The changes in these guidelines emphasize early placement of an advanced airway to limit nosocomial viral transmission and encourage healthcare providers to determine the effectiveness of their efforts prior to placing staff at risk for exposure. Conclusions While treatment priorities and goals are identical to pre-pandemic approaches, the management of COVID-19 patients in cardiac arrest has distinct differences from cardiac arrest patients without COVID-19. We provide a review of the current literature on the changes in cardiac arrest management as well as details outlining team composition.

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“…Hence, it is uncertain whether the HCW should proceed with an actual or perceived “inadequate quality” PPE. Moreover, existing PPE guidelines are not specific to CPR, and some guidelines recommend powered air-purifying respirators (PAPRs) during CPR in patients with COVID-19 [ 4 ]. As the risk of disease transmission during CPR is uncertain, it is unclear whether we should aim for the “maximum” level protection, or be satisfied with “adequate.” However, refusal to treat may result in disciplinary or legal action against the HCW.…”

mentioning

confidence: 99%

COVID-19 pandemic: ethical and legal aspects of inadequate quantity and quality of personal protective equipment for resuscitation

Wong

Lim

Chee

et al. 2021

Korean J Anesthesiol

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The coronavirus disease 2019 (COVID-19) pandemic has implications for cardiopulmonary resuscitation (CPR). Chest compression is an aerosol generating procedure that is associated with a high risk of disease transmission to healthcare workers (HCWs) [1]. Before commencing CPR, guidelines recommend usage of a minimum respiratory personal protective equipment (PPE), "an FFP3 mask (FFP2 or N95 if FFP3 is not available)" [1].Adherence to guidelines may have been challenged in two scenarios. First, there was an "inadequate quantity" (supply) of N95 masks during this pandemic. This rendered the HCWs unable to physically adhere to the guidelines. Second, masks may have been or may have been perceived to be of "inadequate quality" for several reasons [1]. The N95 mask has a lower filtration performance than the first-choice FFP3 mask, i.e., 95% vs. 99% [1], although the clinical significance of this is unknown. Additionally, counterfeit and poor quality N95 masks are being sold. Since chest compression involves vigorous movements, it may lead to poor mask seal, decreased protection rates, and mask failure including strap slipping [2]. Finally, N95 masks undergoing extended use and reuse are associated with disease transmission and decreased functionality [3].Ethical dilemmas and confusions arise in both scenarios. In the "inadequate quality" scenario, the HCW is expected to perform a duty (CPR) adhering to the guidelines (wearing a N95 mask). Hence, it is uncertain whether the HCW should proceed with an actual or perceived "inadequate quality" PPE. Moreover, existing PPE guidelines are not specific to CPR, and some guidelines recommend powered air-purifying respirators (PA-PRs) during CPR in patients with . As the risk of disease transmission during CPR is uncertain, it is unclear whether we should aim for the "maximum" level protection, or be satisfied with "adequate. " However, refusal to treat may result in disciplinary or legal action against the HCW.Various statements and considerations pertaining to a doctor's duty to treat (or not) are shown in Table 1. The duty to treat is guided by the ethical principles of beneficence, non-maleficence, autonomy, and justice [5,6]. As these principles apply to the patient, HCWs and society, there may be conflicting priorities. HCWs have an obligation to prevent self-infection and onward transmission of infections to other patients, their colleagues and relatives, and the wider community [1]. Further, the ethical principle of justice takes into account the right of not being killed by another human being [6] (with a serious infectious disease). Justice also requires hospitals to provide adequate PPE.Moreover, there are the doctrines of expressed consent, implied consent, special training, reciprocity, and professional oaths and codes [5]. Expressed consent includes signing of a contract on the basis that adequate PPE would be provided [5]. Arguments against

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Recommendations on cardiopulmonary resuscitation strategy and procedure for novel coronavirus pneumonia

Cited by 17 publications

References 10 publications

Pediatric Resuscitation Practices During the Coronavirus Disease 2019 Pandemic

Pediatric Resuscitation Practices During the Coronavirus Disease 2019 Pandemic

COVID-19 cardiac arrest management: A review for emergency clinicians

COVID-19 pandemic: ethical and legal aspects of inadequate quantity and quality of personal protective equipment for resuscitation

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