Hello, and welcome to today's Critical Care for Non-ICU Clinicians Expert Panel Series. A heartfelt thank you goes to the sponsor of today's webcast, Thermo Fisher Scientific offers Procalcitonin, a valuable tool to quickly aid in the identification of patients at low risk for bacterial co-infection and bacterial related adverse outcome in lower respiratory tract viral infections such as COVID-19. For more information, please see their website listed here. Our sponsor's website information is available to you in the chat box and will be sent to you one hour after this webcast. You will also have access to this information once the recording has been posted. My name is Dr. Babak Sarani. I am a Professor of Surgery and Emergency Medicine and the Chief of Trauma and Acute Care Surgery at the George Washington University School of Medicine, and I will be moderating today's webcast. This webcast is being recorded. The recording will be available to all registrants within 24 to 48 hours. To access, please go to covid19.sccm.org forward slash webcast. A few housekeeping items before we get started. To submit questions throughout the presentation, type into the question box located on your control panel. Please note that the disclaimer stating that content to follow is for information or educational purposes only. The data have not been peer reviewed. It is based upon a small sample size with key aspects of information missing and a single center experience. This is based on expert opinion. And now I'd like to introduce you to our speakers for the day. Dr. David Ferraro is a Pulmonary and Critical Care Physician at National Jewish Health in Denver, Colorado. Dr. Sophia Rogers is a Critical Care Nurse Practitioner with the Pulmonary Critical Care Service at Lovelace Health Systems in Albuquerque, New Mexico. And Dr. Michelle Papeau is the Medical Director of the Pediatric Intensive Care Unit and Pediatric Transport Team at Medical City Children's Hospital in Dallas, Texas. And now let's get right to it with questions from our attendees. So let's start with maybe more of a general question. And David, if it's okay, I'll direct this one to you. So Dr. Ferraro, if you can kind of walk us through the origin, the start of a resuscitation of a COVID-19 positive patient who comes in tachycardic, how do we fluid resuscitate? When do you fluid resuscitate? Great. That's an excellent question. You know, I think that one of the things that we're seeing with COVID is that while it does have a lot of multisystem organ involvement, the primary pathology is respiratory failure. So oxygen supplementation is certainly one of the most important pieces to early identification and management. Fluid resuscitation comes shortly after. I think that for the most part, we try to employ conservative fluid strategy for, you know, with respect to crystalloid administration just to not overwhelm the lungs and provide additional pulmonary edema and might put someone further into respiratory failure. Okay. And once you've started the resuscitation, continuing with you, Dr. Ferraro, the patient is severely tachypneic, maybe hypoxic, and now the decision has to be made between high flow nasal cannula versus intubation. Can you talk a little bit about that decision tree? And then if you can expand a bit on once the decision is made to intubate, are there anesthesiology teams? Are there dedicated airway teams? How does one go about actually doing that? Yeah, there are a lot of choices when you're talking about oxygen supplementation for patients. And I think that a lot of this has to do with each institution and what their protocols are. Just remember that as we're learning more and more about COVID and kind of the evolving pathophysiology that we can predict for patients, a lot of these strategies can change. Certainly when a patient comes in on room air and it's hypoxic, we're going to apply some pretty simple oxygen strategies such as nasal cannula or perhaps a simple mask. When a patient surpasses those capabilities and we're talking about needing higher FiO2 such as maybe beyond 40 to 50%, we start to think about supplying a non-rebreather or perhaps heated high flow. There is a lot of controversy regarding heated high flow and primarily whether this is an aerosolizing maneuver or not. I think that at least the World Health Organization has avoided verbiage that says to not use heated high flow. So they're at least saying that this may not be a concern, although that the literature from SARS-1 would suggest that there's a potential problem. This has actually been studied most recently in a couple of articles and one that's impressed by Lee in the European Respiratory Journal right now does suggest that heated high flow one, avoids the need for intubation and might salvage those who would have otherwise been intubated and probably doesn't pose a risk of infection transmission to healthcare workers who are potentially not wearing N95 masks and face shields. So I think the question is yet to be answered regarding the safety and the usefulness of heated high flow. But if we go back to previous studies that predate COVID such as the Floralee study, we do see a lot of key improvements in patients who are treated with heated high flow for hypoxic respiratory failure in that it improves their work of breathing, decreases their respiratory rate, their heart rate, and may have a sub-significant improvement in the need for intubation. That being said, a lot of centers are employing an early intubation strategy for COVID. And that also is fraught with some debate because if we're intubating patients early, are we taking patients that otherwise wouldn't have needed to be intubated and putting them on mechanical ventilation and subjecting them to the risks of villi, barotrauma, and other inherent issues with a sedated, potentially paralyzed patient who's bed-bound? So the question of when do we need to intubate patients, what FiO2 is it, what SpO2 should they have, what is our threshold, is probably pretty variable. When you do think about intubating patients, there is a concept that has been utilized in a number of institutions of having an intubation team. Because patients with COVID are certainly at high risk of complications from their hypoxic respiratory failure, it is probably important to have a really high level of skill in the primary intubating clinician. In one of my ICUs that I attend in, we've had intubation teams, and these have been really great. They're generally an anesthesiologist. As our elective cases had subsided, we had a little bit more plethora of anesthesiologists around so that they were a great asset to have, whereas the intensivists remained in the ICU and provided vet management and care planning with families. So the concept of having intubation teams is potentially very beneficial. You utilize a clinician with high skill in intubating. If that person is doing this routinely, they should have a higher skill in donning and doffing, which I think reduces transmission to healthcare workers. You can also bundle procedures. So when our patients at one of my hospitals get intubated, we generally will place a central line as well as an arterial line all at the same time in the room with one clinician as opposed to having multiple room entrances and breaking and doffing of personal protective equipment, which might pose a higher risk. So I'll stop there and see if I've answered your question well enough. Those are pretty big questions. Thanks for the overview. We'll see if the audience wants any other details, and we can certainly pick up the trail. Dr. Serrano, it's Sophia Rogers. I just wanted to point out in the surviving sepsis guideline, the COVID-19, there is a really excellent algorithm that basically goes through how you deal with a COVID-19 patient with hypoxia. It just goes through, does this patient, is he indicated for endotracheal intubation or not? If they are, what do you need to do? If they're not, are they tolerating supplemental oxygen? If not, then consider high flow nasal cannula. So it's a really good algorithm to look at if the audience wants to know more information about that. Excellent. So let me switch gears a little bit. So Dr. Ferrari talks to us about how to food resuscitate, when to food resuscitate and some decision making around high flow nasal cannula versus intubation. And now we've decided that we're going to do one or more of these interventions, but resources are becoming more and more limited due to the number of patients. So if I can turn now to Dr. Rogers, Dr. Pappot, can we start discussing how does one provide care in a resource constrained environment to the increasingly sick, bordering on critically ill COVID-19 patient? I will start first. This is Sophia Rogers. Again, I just like to thank the Society of Critical Care Medicine to allow me to participate in this webcast. Yes, to deal with the onslaught of the COVID-19 patients that are being admitted to ICU, we really have to make sure there's adequate staff to care for them. And we know that there's not enough ICU nurses. So we have to look at other resources. So our institution, as well as others around the country, this is a real challenge. So we start pulling from nurses who are not ICU trained, such as nurses from the progressive care unit, medical surgical units, nurses from procedural areas like PACU, OR, cath lab, GI labs, to have them come in and assist in caring for these patients. But the issue is, how do we train them? So many of the institutions are setting up their own courses. Like at our institution, our critical care educators put together a four-hour course that is mandatory. It talks about mechanical ventilation, interpretation of blood gases, vasoactive drugs to try to get them prepared a little bit better. The Society of Critical Care Medicine also has, in the COVID-19 resources, has an excellent set of lectures. And it's not only for nurses, but also for our APPs who are not in critical care areas and are non-ICU physicians, that there's sets of slides of mechanical ventilation, hemodynamic monitoring, assessment of critically ill patient, acute respiratory failure. Many of these slide sets are from our FCCS course, our Fundamental Critical Care Support course. And it's narrated. It's really excellent. We've even had some of our ICU nurses take it. So that's another way of getting them prepared. The American Association of Critical Care Nurses also has a four-hour course that they put together to try to train these non-ICU nurses and practitioners. And we will have these links in one of our reference slides so that you can access these resources. We've also gone to a team-based approach for caring for these critically ill patients. So what we have is like a little pyramid where you have the ICU nurse as the team leader, and she's in charge of one or two non-ICU nurses, and they take care of a group of patients. So the ICU nurse will be managing the basal active drugs, the mechanical ventilation, whereas the non-ICU nurses may be given routine medications like the antibiotics and their DVT prophylaxis, whatever, and help with vital signs, help with management and care, basic care of these patients. That would be another way of alleviating, taking care of these patients. Also, because I am an advanced practice practitioner, I would be remiss not to talk about how are the nurse practitioner playing a role in caring in this limited resource environment. Let me just state that in 28 states, including District of Columbia, the nurse practitioners have independent practice, but 22 states still require physician oversight. In March, the Secretary of Health and Human Services, Alex Azar, had encouraged governors in each of the states, in those 22 states, to lift the supervision requirements so that we can allow nurse practitioners more flexibility in helping care for these patients. Five states have responded by lifting these requirements, and an additional 12 states have modified them to give the APPs with extra trainings more independence. For instance, in New York, in addition to lifting this supervision, they also have relaxed the record keeping and then also granting immunity from civil liability for any injury or death to these patients, of course, unless there's gross negligence. Many of the institutions like ours actually have non-critical care nurse practitioners who may be furloughed from their job because they're working in general surgery, they're working in the GI labs or IRs, to come and help us work side by side with the critical care nurse practitioner to manage these patients. Maybe they might take a load of patients who are not as sick as the one that the critical care nurse practitioner or APP may be managing. I've also heard from Dr. Sarani, which I did not know, that they're actually in some hospital utilizing APPs as best side nurses, which is an interesting concept. These are some of the things that we're dealing with in taking care of these patients. I did want to also point out that there is actually a document in society critical care medicine called COVID-19 resources, under the resources. Basically, this is for triaging resources during the COVID-19 pandemic. I just want to refer our audience to this. The purpose of these recommendations is basically to just have a transparent and equitable, consistent approach in how to allocate resources that are scarce to COVID-19 patients. They have a nice little algorithm, basically, to have the primary team and triage committee categorize them. Patients are too well for critical care, too sick for critical care, would benefit from critical care, and how these scarce resources would be doled out to these individuals based on their acuity. Michele, you're a pediatric intensivist. What are your thoughts on augmenting capacity and augmenting resources in a resource-constrained environment? First of all, thank you for inviting me to participate in this webcast. I think I can actually probably discuss to centers who have limited or limited ICU resources to respond to a potential surge like pandemics common to COVID-19. I think small and rural centers should never be discouraged that they can't manage surge capacity. I think with some organization, they can go ahead and do it, and they'd be surprised with thinking out of the box what they can do. When you manage surge capacity, I think you need to think about it into four components. Staffing, I'd like to talk about staffing, your stuff, your equipment, your space, and your infrastructure. And if you keep those things in mind, there's a lot that you can do even if you have limited resources. Many of the things on the nursing level that Sophia has discussed have also been patterned on the physician side. There's been expansion of pediatric critical care units to accept adults into their units, teams of physicians that are multidisciplinary that include pediatric intensivists and then telemedicine maybe two or three times a day with adult critical care counterparts on direction of patients, using paramedics along with critical care nurses at the bedside. There's been a lot of work on asking retired physicians in the community to come back and participate, nurse practitioners. So there's a variety of things that need to be just examined in rural centers in terms of their availability and resources. Second, in terms of equipment, that is critical. There's always a lot of, it seems to be a little bit of chaos and supplies seem to be just going out the window at a rapid rate. It's very important even if you're in a resource limited setting or small hospital to work with your administrators and your ICU staff and have a multidisciplinary team to have a list of what you need and what you can accommodate and what you cannot. Many patients who present to hospitals and during a disaster are ambulatory and may not be needed to be admitted to the hospital therefore we've seen pop-up tents outside of every ER trying to screen patients before they come into hospitals so that patients that really need hospital care can get the resources that they need. Finally on space, people really have to think out of the box. I've seen some incredible things people are using as mentioned by Sophia looking at post-recovery areas, looking at even comfort space, people looking at various aspects of their own hospitals in terms of where they can expand patients, ERs, pediatric critical care units expanding to adult patients. So every center has capability to mount their appropriate surge capacity. And finally I think people need to consider contacting their local health department, working with their administrations and possibly having some relationship with a tertiary center that can provide advice and assistance for actually triaging patients that are sick and hopefully mobilizing or transporting them to a higher level of care. Again Dr. Serrani will outline the access on the FCCM website where there's multiple resources, many coming from the fundamentals that can be of great use to even centers that are in a rural or limited setting. Yeah if I may expand on some of the points that the two speakers raised. In regards to utilizing advanced practitioners as a means to augment the nursing core, there are several hospitals that have asked people who are a nurse practitioner and or a CRNA specifically to assume the role of a registered nurse. Fundamentally they are registered nurses and come into the ICU. As well remember that particularly in areas of the country that are still closed to elective surgical cases, that drops the census on these surgical services quite a bit and that frees up the physician assistants who although they cannot assume the role of a registered nurse, certainly are quite capable clinicians and may be retasked to another area of a hospital. So in totality that does offer a good means to augment one's bedside provider force utilizing these advanced practitioners. You just need to be cognizant of the local rules from your Department of Health and make sure that you abide by the regulations therein. The last point that Dr. Pappot just raised about the the resource page on the sccm.org website, the COVID-19 resource page. We'll hit on that a couple of times. We're going to talk about proning in a few minutes. There were some questions regarding that. But as a case in point, if you go to the COVID-19 banner which is on the homepage and navigate your way over to educational resources, you'll see a series of videos as well as some narrated PowerPoints. The videos in particular I would direct the audience's attention to. They're essentially just in time training videos. They're about 15 to 20 minutes each. They're not very long at all. By a variety of speakers within the society talking about how to do each of these interventions. So for example, how do you prone somebody? What is your initial approach to assessment of the critically ill patient? There's a video on basics of mechanical ventilation which I see some questions coming in on. And because we don't have time within one hour to hit these topics in any depth, I would very strongly recommend people listening to avail themselves of that opportunity. I was going to ask a couple of other questions but there's a few coming in online. So maybe I'll redirect for a second. Question for any of the audience, any of the panelists. It says, do you ever send patients home or to a long-term care facility while still on supplemental oxygen? What about non-invasive ventilation or high flow? So any type of oxygen therapy, let's go from nasal cannula all the way to high flow. Are you guys discharging or do they have to be off their oxygen? This is Sophia. We do discharge our patients with supplemental oxygen but they won't take them on high flow. At one point they were not taking them if they they had to test negative before they would take them. But now we are getting a backlog of patients and not being able to move them out. So the LTACs, and we only have two in the city, are relaxing their rules and they are going to start taking our COVID positive patients. But anything more than five liters nasal cannula or so, they won't take. They have to be on fairly low and that's stable. And you're titrating for an O2 sat 90% or higher? Yeah, exactly. Yeah. David? Our local LTACs are able to take our patients all the way up to utilizing mechanical ventilation. Our patients generally must be PCR negative times two and that's usually done approximately 24 to 48 hours apart. We are not sending patients on heated high flow but I don't think that's usually a practice of ours anyways. And on a similar question, a audience member was asking, can you give me an algorithm for O2 supplementation? So how do you dial up from routine nasal cannula all the way up to intubation? What are your thresholds for moving from one tier to the next in terms of O2 saturation? I think that there's really not a secret to escalating oxygen therapy. The question is where do you draw the line on intubation? So you know in the surviving sepsis guidelines for COVID as well as the World Health Organization, there are some vague generalizations to be made about what your goal SpO2 is and generally that's about 90 to 92 percent. So that's kind of what we're titrating our oxygen therapies for. In general, most facilities are still adopting an early intubation policy unless they have ample spaces for utilizing heated high flow or non-invasive. But in general, I think it's wise to be cognizant of the acceleration of oxygen needs. What we've seen with COVID patients with hypoxic respiratory failure is they can crash very quickly. So if you have a patient that starts out at two to four liters per minute and all of a sudden a couple of hours later they're you know on eight to ten liters of nasal cannula, you might even think about intubating at that point. We are generally going straight from nasal cannula to a non-rebreather and the non-rebreather is just serving as a bridge before we prepare for intubation. So, we do use a lot of high flow nasal cannula so we we get a lot of referrals. We're a tertiary center and we serve a quite a few Pueblos and in the McKinley County we have a tremendous number of patients there and they're little small hospitals just overwhelmed. So a lot of these patients come already intubated to us and I wanted to address what David was talking about earlier about having an intubation team. We did have an anesthesiologist 24-7 that were doing that but so many of our patients have come in from outside community they're already intubated that we didn't have a need for them. So unfortunately they've done away with the team but it's the same thing a lot of these patients come in they're on high they're on a high amount of oxygen, a non-rebreather and then we progress them to a high flow nasal cannula and once we start seeing the worker breathing going up they're desaturating we very quickly go to proceed with intubation before they crash and they do crash quickly. We're kind of the same as Sophia's hospital in that one of the very first things we did was allow the use of high flow nasal cannula on the regular medical surgical ward which previously was not the case those were patients in the ICU. So working with our nursing core as well as the respiratory therapists and the hospitalists of course we were able to expand capacity simply by keeping those people on the med-surg ward and that allowed us to save ICU beds. Having said that once someone starts dialing up on their high on their high flow nasal cannula then yes the next step will be to come into the intensive care unit and then we'll be looking fairly quickly at possibly intubating them. This is Michelle and I would say from the pediatric end even though the cases are much much much fewer beyond the adult side that we done from looking at the data from 183 PICUs from the COVID-19 dashboard that basically most centers are following along with high flow heated high flow nasal cannula and if patients rapidly progress obviously they're intubated and placed on mechanical ventilation. So it parallels what's being done in the pediatric side. Do you mind if I jump in for a quick response? Please do, please do. Just to play the devil's advocate here I think it's important to think about at the time of intubation and the key importance of pre-oxygenation. It has been recommended to try to avoid the use of bag valve mask ventilation which is a key component of pre-oxygenation and usually buys time during apnea when someone's pushing RSI medications and preparing to intubate. So you know one of the rationales for intubating early and potentially trying to avoid heated high flow nasal cannula oxygen is that once your patient gets hypoxic enough the ability to pre-oxygenate and provide a safe intubation procedure that window becomes very narrow and so that's just that's always one thing to consider. Me personally having intubated many patients with COVID these are some of the scariest intubations I've done and it strictly relates to the difficulty in pre-oxygenating our patients. I totally agree with that. It is. I've done quite a few recently too and I don't know if you guys are using that little acrylic box. We have to wear the respirator of course and we use an acrylic box which is kind of it's a little learning curve trying to intubate with like playing a video game which I've never been good at but no I totally agree with you on that. They desaturate very quickly. You're looking up and they're setting 20% and you've got to move fast on these patients. So on the same theme of airway and oxygenation let us transition over to prone therapy. Are we proning people while they're awake? If so how do they tolerate it and what about when they're intubated you know what's the role of proning? Why don't we start with David? Yeah it's quite an interesting concept to prone awake patients. Traditionally we've regarded proning as a procedure that's done on sedated and mechanically ventilated patients. Just for the audience I think it's important to briefly discuss why we prone patients. So the physiologic benefits are that we offload the heart. We make the heart anterior in a prone position as opposed to laying on the chest in the supine position. So we increase the homogeneity of pleural pressure gradients. We improve FRC which decreases the shunt ratio. If you think of the lungs as a triangle with the hypotenuse on the back in the supine position that's your greatest surface area. So if you flip that over and make that anterior or upwards then you can improve your ovular surface area and improve recruitment. So those are the potential benefits of proning. In ICU we're proning almost all of our patients once they reach a P to F ratio 150 or lower. That's kind of based off of the PROSIVA trial from New England Journal Medicine around 2013. And we're proning often so we're proning you know 10 to 16 hours a day every day until we find that patients have P to F ratios better than 150. Switching over to awake proning there's been some really interesting studies lately that have talked about the benefits but going back to 2015 there's a study from Scarabilli in Journal of Critical Care where they postulated this concept and they proned 15 patients 43 times with respiratory failure who were not intubated. They were either on non-rebreather or non-invasive. And when they proned them their P to F ratio went from 124 on average to 187 and then stayed above 140 after proning. So that was kind of the rationale for the proof of concept. Lately there's been a couple small studies. One in from an emergency department in New York City that took 50 hypoxic patients that otherwise would have been intubated and they awake proned them and 76% of them did not require intubation. A quick study out of China also this year showed that for awake proning along with some other early recognition modalities led to increased increased survival. It's certainly an interesting concept of proning an awake patient. Not all patients tolerate this but in the ones that do tolerate it I think it's one of the simplest you know least invasive least deleterious things that we can do and many centers have had a lot of success with this. I totally agree. Let me again point to the COVID-19 resources. Dave Drees at Regional Hospital has put together a document on prone positioning for the alert non-intubated patient that you can refer to. It's a really good document. It's basically essentially what we do. The important thing is when you do prone these patients whether they are intubated or not intubated is that you need to the first 15 minutes or so just watch them very carefully. You need to monitor their vital signs. You need to monitor how well they're tolerating the procedure. On the resource page there's also a little video that his team put together for proning the intubated patients and we actually set up certain times to prone all patients. We have three ICU so we try to prone all the patients starting at noon and we have a team that goes around and prones them and then at 3 in the morning we unprone them. We go through and and systematically unprone and prone the patients. We always have a react nurse or a lead respiratory therapist who could re-intubate the patient if they need to if the airway ever got dislodged and knock on wood we haven't dislodged an airway yet but they basically control the airway and yeah when these patients are not doing well and when you prone them their oxygenation does improve as Dr. Farrar had talked about the mechanism of that. So we do it on our patients as well. An interesting question just came in online which is are you feeding your patients while they're proned? Let's assume that their airways are protected, they're not prone and awake. Yeah this is David. I'm not a nutritionist and I cannot tell you what happens but we're having some difficulty with residuals in prone patients. You know we are keeping their head above their stomach as much as possible usually 20 to 30 degrees but we're having to stop two feeds quite a bit and I don't know if that just has to do with the nature of their critical illness and before this it's not like we've proned large amounts of patients in the ICU at a time so maybe I just had ignored that concept before. We usually do a little trickle feed. Michelle, I'm sure there's not much data like I don't have any data regarding proning. No. Well there's not, there's actually a large study that's actually taking place. It's called the prospect study. It's a prone conventional ventilation oscillation pediatric clinical trial that was actually started before this whole COVID thing came out and so pediatric centers are looking in. We do a lot of prone positioning especially in our pediatric ARDS patients. In terms of feeding, I would say it's sometimes it works and sometimes it didn't. We try to do ND feedings when we can but I would agree with David. Sometimes it works, sometimes it doesn't. So there's a couple of questions. What's a trickle feed? That's about a feed that goes 10 to 20 cc's per hour so you kind of just dribble it in. The idea being that you're feeding the villi of the intestine albeit you're not meeting the caloric needs overall but you're trying to maintain the intestinal integrity to minimize bacterial translocation. And there was another question that said there's a comment I guess. There's recommendations by Aspen regarding prone feeding and I would echo that. To be honest with you, I personally am a pretty religious heavy feeder so I tend to feed all of the patients that are prone albeit I don't deal with the COVID patients myself very commonly since I'm in the in the surgical ICU but in general if I have a patient that's prone I'm more likely than not feeding them. Let me, there's a couple of things that I really want to touch base on and there's about 20 minutes left so let me switch gears for a second to the pediatric world and then hopefully we'll have time to come back to the adult world. But I do think that we need to spend some time discussing the pediatric multi-system inflammatory syndrome. So Dr. Pappal, if I can ask you to take the lead on that. Well this is becoming quite interesting. I think to everyone who is in pediatrics, we thought we were going to snake by in COVID-19, not being inundated with a lot of patients, at least pediatric patients. And late April, there was a report coming out of the UK from the Royal College of Pediatrics and Child Health about children presenting with a toxic shock picture with incomplete Kawasaki disease. We'll talk about that in a second, experienced GI symptoms and cardiac inflammation, and at times, shock presenting to the hospital. So there were numerous cases starting to crop up in the UK, and then now we have a whole series in New York, and now several states have been looking at this closer and have seen cases. So actually, this is thought to be maybe a post-infectious inflammatory condition, potentially an inflammatory disease or vasculitis, but children are coming in and presenting with persistent fever from four to five days. We're having evidence of elevated inflammatory markers, and that can include really elevated C-reactive proteins, elevated SED rates, elevated ferritins and D-dimers, and some are presenting in shock, a toxic shock picture that we've commonly seen with strep sepsis or toxic shock or staph toxic shock, and requiring high nasal pressure support. Some of the parameters are similar to Kawasaki's disease, which is thought to be a generalized inflammatory disorder of generalized vasculitis and most pronounced, causing coronary artery inflammation and potentially aneurysms. Kawasaki's is usually seen as a disease that we see in less than, kids more or less less than five that have high fever, severity of four to five days, they get a rash, they have surgical adenopathy, conjunctival injections, and mucositis, and then they get erythema of the palms and claws, soles of their feet, and even desquamation of the fingers and toes. And there's certain criteria for this, but prolonged fever seems to be part of the picture. So, at this point, I think we need to take notice as clinicians that not all children, we've always thought children may be having mild illness related to COVID-19, but a child that presents with persistent fever, that has abdominal pain, a single or multi-organ dysfunction that can come in with abdominal pain and acute kidney injury, or have multi-organ dysfunction, include shock and cardiopulmonary symptoms, and they may be PCR positive, or a large number are negative and are antibody positive, which would go along with the thoughts that this might be a post-infectious inflammatory condition. So, the word is out on this, but I think it's important for clinicians who see children like this to get cardiology and ID involved right away, the inflammatory markers, have them evaluated. These children need echocardiography, and actually many respond to IVIG, aspirin, and other therapies. So, it's a condition that's evolving and emerging, and we need to be aware of that. Okay, I don't see any comments coming in regarding that, so thank you for the overview. Let's move forward a little bit, maybe back, hopefully, more to the adult world. I'd like to address coagulopathy. There's been a lot of reports, both in the medical literature as well as in the lay press, about patients who show up with thrombi, if not emboli, throughout. So, Sophia, you want to discuss coagulopathy, and are you guys putting everybody on heparin? Well, first of all, let me just say these patients with COVID-19, they are at increased risk for developed venous thromboembolism, just because they're in the hospital, they're immobilized, in isolation, and likely the infection itself. And this has been associated with coagulopathic presentation. It looks a lot like DIC. They're more thrombotic rather than hemorrhagic. You'll see them with the elevated D-dimer, prolonged PT ratio, low fibrinogen, thrombocytopenia. So, what's important is that we definitely want to VT prophylaxis these patients, unless it's contraindicated, like they have an active bleeding, or they have a really low platelet count. So, normally, we divide them into whether they're critically or non-critically ill, and this is, we base it on the literature, and that's ever-changing also. So, for non-critically ill patient, we use noxiparin, 40 milligrams once daily. Unless they have a creatinine clearance less than 30, then we go to unfractionated heparin, and that's usually 5,000 every eight hours. If they are critically ill, then we increase the dosage. Again, if they can tolerate low molecular weight heparin, we give them 0.5 milligram per kilogram every 12 hours, and that's fairly new. And in our morbidly obese patients, we have a lot of morbidly obese patient within our COVID population. If their creatinine clearance is less than 30, then we use 7,500 units every eight hours. You know, definitely, it's really challenging diagnostic studies on these patients, because the scarcity of the resources and the turnaround time to get a patient to do a CT NGO is about an hour. We have to, it's a big deal to transport these patients, at least it is our facility. I like to hear if that's the same way. And once they get their test, then they have to terminally clean the CT scan, or they're too unstable for us to transport them. But if we start seeing patients that have an extremely high D-dimer, where they're grading 3,000, we're seeing them have persistent clotting of lines, we're seeing them having a worsening clinical course. I had a patient two nights ago who precipitously dropped her SAT, became tachycardic, became tachycardic, tachypneic, and she was too sick for me to transport her for a CT NGO. So I empirically started her on a Heparin drip. So it's a real challenge in taking care of these patients, but absolutely, these patients definitely VTE prophylaxis. And if they are bleeding and they can't tolerate pharmacologic prophylaxis, then they need to have the SCDs. Dr. Ferraro, what's practice at your facility? It's roughly the same. We're starting to do at least some intermediate version of anticoagulation for our mechanically ventilated ICU patients. But just like Sophia said, all of our ICU patients are on some version of chemoprophylaxis for VTE, as long as there's no contraindications. I have to admit... Go ahead, I'm sorry. Oh, no, please go ahead. I have to admit we're a bit more aggressive than your two centers, and I'd like to see what Michelle says as a pediatric provider, but we are as concerned about arterial thrombus as we are about venous. And so when I was speaking with the medical director of our intensive care unit, Dr. Danielle Davison, she commented to me that all the patients in the ICU who are COVID-19 positive are on therapeutic anticoagulation, full-bore heparin drips, titrating to the PTT, unless there's a contraindication against that. So we are not relying on DVT prophylaxis per se because of the arterial component that we're also concerned about. There was a study just published last week in the Journal of American College of Cardiology, and basically they did exactly what you're talking about. Any mechanically ventilated patients, critically ill, COVID-19, they are given them therapeutic heparin, and they're seeing some decrease in mortality as a result. So it'll be interesting. They talked about some confounding factors, and I'd like to have a little bit more complete on this study, and they want to do a randomized control trial because this is an observational study, but that's something that, yeah, we're looking at as well. Michelle, we know from the trauma literature that the incidence of pediatric DVT is substantially lower than adult DVT-PE. So what are you guys doing for COVID-19 in the pediatric patient? Well, I would say that at least of what occurred out in New York and in New Jersey, that at least some of the patients that are at least on oxygen or rapidly progressing, people are using low molecular weight heparin and considering prophylaxis. It's not something in pediatrics we do routinely unless kids are around teenagers and we start pursuing all that. But yes, I can't really give a definitive comment on that. Probably the people from New York would have a better comment on that. But yes, I guess children that are on substantial oxygen or rapidly progressing have a higher chance of being at least low molecular weight heparin for COVID-19. We only have about eight minutes left. I'd like to hit two topics. There's a recurrent theme in the questions coming in, and that is regarding delivery of calories. And the more recent couple of questions from various people discuss the amount of calories patients are receiving from high-dose propofol infusions because of the difficulty in sedating these patients. And how do you balance that against the nutrition that you're actually providing them? I'll tell you at my facility, we immediately identified that the propofol alone is simply not enough to sedate these patients. Ketamine seems to be extremely helpful. And at George Washington, we're a very heavy ketamine shop to begin with for pain relief in particular. And so it's very easy for us to co-infuse ketamine. I've also seen many of my colleagues co-infusing dexmedetomidine as a means to lower the propofol dose as a whole and get more of a balanced overall sedation regimen. And I guess as a side effect, nutrition. But in just a couple of minutes, if you guys can opine upon sedation, propofol, calories, and then I'd like to spend the last couple of minutes talking about CPR in patients with COVID. Well, this is Sophia. We have a nutritionist that works in our ICU, and they help us calculate what kind of calorie, caloric intake the patient needs. We have a shortage of propofol. So we're not using propofol as much. We're having difficulty getting it. So we're using a dexmedetomidine more than, or versedurep, using for sedation more than we are using propofol. But we basically leave that when we make rounds, she usually calculates all the calories and let us know what the patient needs and calculates it for us. And we put in the order by their recommendation. David, sedation? Specifically on sedation, we have had the same issue with propofol. We have had a serious shortage of that as well as fentanyl and dexmedetomidine. We have actually come to some quite novel, well, not novel, but just what was done 20 or 30 years ago, where we started to put meds down the NG and OG tube again. So in order to minimize our need for IV sedation and analgesia, we have been using medications like oxycodone, lorazepam oral, and Seroquel to provide some background sedation and analgesia so that we can preserve those medications, ideally for the patients that have been just recently intubated, just to maintain sedation for them definitively. As far as the propofol and caloric adjustment, yes, we know that there are calories in propofol, but not ideal ones. So our in-ICU nutritionist also helps us adjust our nutritional needs for the patients that are on propofol. From the pediatric standpoint, I would just say that because of the idiosyncratic side effects of propofol, it's not used as a common agent to sedate kids. It can range from propofol infusion syndrome to cardiovascular collapse. However, on children who are on noninvasive ventilation as well as high flow, we use a lot of ketamine drips. Dexmedetomidine has been king for us. We use that medication quite a bit, and we also do, at times, a combination where we use enteral medications like Ativan and methadone along with infusions of Dexmed and our non-intubated patients for patients who are on noninvasive and then fentanyl versus in the gamut of whatever else on intubated patients. All right, and we have about four minutes left, so let's transition to CPR in the patient who is COVID-positive, PPE, protection of the team, how do you approach this entity? So the American Heart Association just published in Journal of Circulation April 15th about this exact issue you're talking about. And what they're saying is that all rescuers, they highly recommend should don their personal protective equipment before entering the room to do CPR. They also recommend minimizing the number of people who are in the room at our facility. We only allow four people in the room. That's usually the provider. The respiratory health care provider, the respiratory health care provider, and the the provider, the respiratory therapist, a nurse who push drugs, and then an extra person to assist with CPR. We do not, and as the American Heart Association also recommends, not disconnecting them from the ventilator because it is a closed system. I would just crank, make sure the oxygen is cranked up to 100%. And if you are going to use a bagged mask device to make sure there is a HEPA filter and that you have a tight seal. But a lot of times what we do as well, what they're recommending is just giving them passive oxygen with a non-rebreather and putting a surgical face mask on them before intubation just to get their oxygen up a little bit. And they said to consider manual ventilation if intubation is delayed to use a supraglottic airway or again a bagged mask device with a HEPA filter. They also wanted to point out, as it is in the limited resource literature, that if you felt the mortality for these patients are going to be high with increasing age and comorbidity, that perhaps that you have to look at the appropriateness of resuscitation. You have to balance that with the likelihood of success against the risk to the rescuers. They also recommend using the mechanical chest compression for CPR rather than having the providers do the manual or do the chest compression. And then make sure that, and if the patient does expire, to not transport the patient, COVID positive patient, to the hospital if you don't get ROS. So that's a document that was just recently released. Dr. Pappot, any other thoughts? In terms of ventilating patients during CPR, keeping them on the ventilator is, if they are intubated and using a pressure control mode, making sure the triggers are off, the alarms are off, adjusting your rate to get 10 breaths for adults, 30 per minute for pediatrics, trying to achieve about six cc's per kilo of ideal body weight, targeted about four to six cc's per kilo if it's a child, trying to limit your PEEP for adequate venous return. These are some other things that are people, what are advocated in these interim guidelines for COVID-19 and CPR using ventilatory support during the CPR process. Also, I might add one additional thing is of curiosity is providing CPR in patients who are prone. I mean, if you can turn them around to do CPR in the supine position, fine. If not, they're advocating defibrillator pads in the anterior posterior position. Continue the patient in the prone position and use the standard hand position over T7 to T10 over the ventricular bottom and perform CPR in that position. So those would be the additional things in that report, interim guidelines from the AHA. Okay. Well, you know, as they say, time flies when you're having fun. So unfortunately, our one hour Yeah, I did. I'd like to thank really my colleagues and fellow panelists, Drs. Ferraro, Rogers, and Papeau for your time and for your input. Thermo Fisher Scientific offers procalcitonin, a valuable tool to quickly aid in the identification of patients at low risk for bacterial co-infection and bacterial related adverse outcome and lower respiratory tract viral infections, such as COVID-19. For more information, please visit their website listed here. Our sponsor's website information will be sent to you one hour after this webcast. You will also have access to this information once the recording has been posted. Thank you again to the audience for attending. And again, this webcast was recorded and the recording will be available to registrants within 24 to 48 hours. Please go to covid19.sccm.org forward slash webcast to see it. That concludes our presentation today. I'd like to thank the Society of Critical Care Medicine and all involved in putting this on. Thank you and have a wonderful evening. Thank you. Thank you. Thank you.

critical care

non-ICU clinicians

COVID-19 patients

procalcitonin

resuscitation

fluid resuscitation

high flow nasal cannula

intubation

oxygen supplementation

CPR