Coronavirus/COVID-19 resources: Other resources

Link: Gale Health and Wellness database
Password: hwrc

The IARS has convened a Scientific Advisory Board to curate the thousands of emerging peer-reviewed journal articles on COVID-19 and highlight those of greatest value to anesthesiologists, intensivists, related specialists, and investigators. The articles featured here are the result of extensive review and discussion among our panel of experts. Featured articles are openly available on their respective journal websites. Journal CME is available for selected articles.

ASM has also committed to making all of its COVID19 and coronavirus related publications, and the available data supporting them, immediately accessible in PubMed Central (PMC) and other public repositories.

EVERYTHING WE KNOW ABOUT THE COVID-19 CORONAVIRUS

The resources on these pages are designed to help you have conversations about what matters most to your patients and their whānau. They are easily accessed, clear and consistent, and are based on sound principles, evidence and experience.

Intubatecovid.org is now online, and registration can be completed in less than one minute by clicking the “Sign Up” button on the homepage.

Medical specialists from the affected countries can register to get free access. This free access applies through the end of June 2020, and stops automatically. If the outbreak lasts longer than expected, Medicom may extend the period of the free membership.

This dataset is intended to mobilize researchers to apply recent advances in natural language processing to generate new insights in support of the fight against this infectious disease. The corpus will be updated weekly as new research is published in peer-reviewed publications and archival services like bioRxiv, medRxiv, and others.

SSRN, Elsevier’s world-leading platform devoted to the rapid worldwide dissemination of early-stage research, is committed to making coronavirus-related research available immediately. Research on SSRN is free to download and upload. It is important to note that these papers have not benefited from the pivotal role of peer-review, which validates and improves the quality of final published journal articles.

Abstract
The treatment of surgical patients who are confirmed or suspected of coronavirus disease 2019 (COVID-19) is a challenge for all anesthesiologists. The safety of both patients and healthcare workers should be taken into consideration when performing anesthesia management for patients with COVID-19. General anesthesia requiring airway intervention may exacerbate COVID-19 pneumonia, and aerosol generation during airway intervention risks COVID-19 transmission to medical staff. However, regional anesthesia is not an aerosol-generating procedure. The neuraxial anesthesia may have little adverse influence on clinical outcomes in patients with COVID-19 after reviewing previous case reports. Regional anesthesia may have some advantages over general anesthesia for this group of patients, but unplanned conversion to general anesthesia during surgery is not preferred. Thus, careful consideration should be given to ensure that the surgery is performed entirely under regional anesthesia. The use of ultrasound guidance and the performance by an experienced physician may reduce the incidence of failed block and complications. The use of long-acting local anesthetic prolongs the anesthetic effect of regional anesthesia. Besides, a safe and sufficient dose of local anesthetic should be used.

Abstract
Background: Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death.

Methods: In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the preliminary results of this comparison.

Results: A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55).

Conclusions: In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.).

Abstract
COVID-19 is a rapidly spreading global threat that has been declared as a pandemic by the WHO. COVID-19 is transmitted via droplets or direct contact and infects the respiratory tract resulting in pneumonia in most of the cases and acute respiratory distress syndrome (ARDS) in about 15 % of the cases. Mortality in COVID-19 patients has been linked to the presence of the so-called "cytokine storm" induced by the virus. Excessive production of proinflammatory cytokines leads to ARDS aggravation and widespread tissue damage resulting in multi-organ failure and death. Targeting cytokines during the management of COVID-19 patients could improve survival rates and reduce mortality.

Abstract
Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in late 2019 and spread globally, prompting an international effort to accelerate development of a vaccine. The candidate vaccine mRNA-1273 encodes the stabilized prefusion SARS-CoV-2 spike protein.

Methods: We conducted a phase 1, dose-escalation, open-label trial including 45 healthy adults, 18 to 55 years of age, who received two vaccinations, 28 days apart, with mRNA-1273 in a dose of 25 μg, 100 μg, or 250 μg. There were 15 participants in each dose group.

Results: After the first vaccination, antibody responses were higher with higher dose (day 29 enzyme-linked immunosorbent assay anti-S-2P antibody geometric mean titer [GMT], 40,227 in the 25-μg group, 109,209 in the 100-μg group, and 213,526 in the 250-μg group). After the second vaccination, the titers increased (day 57 GMT, 299,751, 782,719, and 1,192,154, respectively). After the second vaccination, serum-neutralizing activity was detected by two methods in all participants evaluated, with values generally similar to those in the upper half of the distribution of a panel of control convalescent serum specimens. Solicited adverse events that occurred in more than half the participants included fatigue, chills, headache, myalgia, and pain at the injection site. Systemic adverse events were more common after the second vaccination, particularly with the highest dose, and three participants (21%) in the 250-μg dose group reported one or more severe adverse events.

Conclusions: The mRNA-1273 vaccine induced anti-SARS-CoV-2 immune responses in all participants, and no trial-limiting safety concerns were identified. These findings support further development of this vaccine. (Funded by the National Institute of Allergy and Infectious Diseases and others; mRNA-1273 ClinicalTrials.gov number, NCT04283461).

Copyright © 2020 Massachusetts Medical Society.

Abstract
During the SARS-CoV-2 pandemic in 2020, departments of anesthesiology worldwide have encountered new and unique challenges. In this short communication, we present and assess our recommendations for orotracheal intubation, a frequent high-risk procedure. We will point out that interdisciplinary cooperation with "non-patient care" departments like the Institute for Medical Microbiology and Hygiene tremendously helped us in creating this and other new, clear standards for anesthesiological procedures. Moreover, to reliably implement our newly created measures, we distributed incisive posters and organized comprehensive training sessions. Eventually, we summarize and analyze the occurring problems of our suggestions for intubation during their realization.

Abstract
Importance: The coronavirus disease 2019 (COVID-19) pandemic, due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a worldwide sudden and substantial increase in hospitalizations for pneumonia with multiorgan disease. This review discusses current evidence regarding the pathophysiology, transmission, diagnosis, and management of COVID-19.

Observations: SARS-CoV-2 is spread primarily via respiratory droplets during close face-to-face contact. Infection can be spread by asymptomatic, presymptomatic, and symptomatic carriers. The average time from exposure to symptom onset is 5 days, and 97.5% of people who develop symptoms do so within 11.5 days. The most common symptoms are fever, dry cough, and shortness of breath. Radiographic and laboratory abnormalities, such as lymphopenia and elevated lactate dehydrogenase, are common, but nonspecific. Diagnosis is made by detection of SARS-CoV-2 via reverse transcription polymerase chain reaction testing, although false-negative test results may occur in up to 20% to 67% of patients; however, this is dependent on the quality and timing of testing. Manifestations of COVID-19 include asymptomatic carriers and fulminant disease characterized by sepsis and acute respiratory failure. Approximately 5% of patients with COVID-19, and 20% of those hospitalized, experience severe symptoms necessitating intensive care. More than 75% of patients hospitalized with COVID-19 require supplemental oxygen. Treatment for individuals with COVID-19 includes best practices for supportive management of acute hypoxic respiratory failure. Emerging data indicate that dexamethasone therapy reduces 28-day mortality in patients requiring supplemental oxygen compared with usual care (21.6% vs 24.6%; age-adjusted rate ratio, 0.83 [95% CI, 0.74-0.92]) and that remdesivir improves time to recovery (hospital discharge or no supplemental oxygen requirement) from 15 to 11 days. In a randomized trial of 103 patients with COVID-19, convalescent plasma did not shorten time to recovery. Ongoing trials are testing antiviral therapies, immune modulators, and anticoagulants. The case-fatality rate for COVID-19 varies markedly by age, ranging from 0.3 deaths per 1000 cases among patients aged 5 to 17 years to 304.9 deaths per 1000 cases among patients aged 85 years or older in the US. Among patients hospitalized in the intensive care unit, the case fatality is up to 40%. At least 120 SARS-CoV-2 vaccines are under development. Until an effective vaccine is available, the primary methods to reduce spread are face masks, social distancing, and contact tracing. Monoclonal antibodies and hyperimmune globulin may provide additional preventive strategies.

Conclusions and relevance: As of July 1, 2020, more than 10 million people worldwide had been infected with SARS-CoV-2. Many aspects of transmission, infection, and treatment remain unclear. Advances in prevention and effective management of COVID-19 will require basic and clinical investigation and public health and clinical interventions.

Abstract
Recently published case reports relating to anesthesia in patients with coronavirus disease (COVID-19) were reviewed. The diagnosis of COVID-19 was confirmed by positive results of reverse transcriptase polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Numerous reports handled emergency cesarean delivery. Primary symptoms and laboratory data of pregnant women with COVID-19 were similar to those of non-pregnant patients. Although the mortality rate is reported to be high after surgery in patients with COVID-19, cesarean delivery was successfully performed under regional anesthesia in most cases and postoperative course was favorable both in the parents and newborns. There is no direct evidence of vertical mother-to-child transmission of SARS-CoV-2; however, a diagnosis of COVID-19 was made in a newborn two hours after delivery from a pregnant woman with COVID-19, based on the increased immunoglobulin levels and deranged liver function, suggesting that its possibility cannot be completely eliminated. Emergency cerebral shunt reconstruction was performed repeatedly in an eight-month-old boy with COVID-19. The tracheal tube was removed in the operating room after surgery and postoperative course was uneventful. All the procedures should be performed in isolated operating rooms with medical staff with level-3 personal protection to ensure the safety of patients and health care providers.

Methods: A single ventilator in pressure control mode was used with flow control valves to simultaneously ventilate two patients with different lung compliances. The system was first evaluated using high-fidelity human patient simulator mannequins and then tested for 1 h in two pairs of COVID-19 patients with acute respiratory failure. Patients were matched on positive end-expiratory pressure, fractional inspired oxygen tension, and respiratory rate. Tidal volume and peak airway pressure (PMAX) were recorded from each patient using separate independent spirometers and arterial blood gas samples drawn at 0, 30, and 60 min. The authors assessed acid-base status, oxygenation, tidal volume, and PMAX for each patient. Stability was assessed by calculating the coefficient of variation.

Results: The valves performed as expected in simulation, providing a stable tidal volume of 400 ml each to two mannequins with compliance ratios varying from 20:20 to 20:90 ml/cm H2O. The system was then tested in two pairs of patients. Pair 1 was a 49-yr-old woman, ideal body weight 46 kg, and a 55-yr-old man, ideal body weight 64 kg, with lung compliance 27 ml/cm H2O versus 35 ml/cm H2O. The coefficient of variation for tidal volume was 0.2 to 0.6%, and for PMAX 0 to 1.1%. Pair 2 was a 32-yr-old man, ideal body weight 62 kg, and a 56-yr-old woman, ideal body weight 46 kg, with lung compliance 12 ml/cm H2O versus 21 ml/cm H2O. The coefficient of variation for tidal volume was 1.4 to 7.7%, and for PMAX 0 to 2.1%.

Conclusions: Differential ventilation using a single ventilator is feasible. Flow control valves enable delivery of stable tidal volume and PMAX similar to those provided by individual ventilators. : WHAT WE ALREADY KNOW ABOUT THIS TOPIC: In previous mass casualty situations where intensive care unit or emergency room surge conditions have resulted, the use of ventilator splitting to ventilate two or more patients has been proposed.The concept has received renewed attention with the global COVID-19 pandemic.The impaired respiratory mechanics similar to the acute respiratory distress syndrome seen in COVID-19 patients pose significant engineering challenges to optimally ventilate one patient while preventing damage to a paired patient.

What this article tells us that is new: Custom designed three-dimensional printed inspiratory flow control valves designed to allow individualized setting of tidal volume and airway pressure were evaluated using high-fidelity simulator mannequins with similar or different lung compliance and were found to perform as expected with stable tidal volumes delivered to each mannequin.Testing for 60 min in two pairs of volunteer COVID-19 patients with acute respiratory failure, matched on positive end-expiratory pressure level, fractional inspired oxygen tension level, and respiratory rate, demonstrated stable system performance. Continuous assessment of tidal volume and peak airway pressure in each patient during the study allowed for dynamic alteration of tidal volume in response to respiratory acidosis.This study suggests that custom designed flow control valves may facilitate the use of split ventilation techniques in a surge setting.

Abstract
The coronavirus disease 2019 (COVID-19) pandemic is caused by a coronavirus that is transmitted primarily via aerosol, droplets or direct contact. This may place anesthetists at higher risk of infection due to their frequent involvement in aerosol-generating airway interventions. Many anesthethetic COVID-19 guidelines have emerged, whose underlying management principles include minimizing aerosol contamination and protecting healthcare workers. These guidelines originate from Australia and New Zealand, Canada, China, India, Italy, Korea, Singapore, the United States and the United Kingdom. Hospitalized COVID-19 patients may require airway interventions, and difficult tracheal intubation secondary to laryngeal edema has been reported. Pre-pandemic difficult airway guidelines include those from Canada, France, Germany, India, Japan, Scandinavia, the United States and the United Kingdom. These difficult airway guidelines require modifications in order to align with the principles of the anesthetic COVID-19 guidelines. In turn, most of the anesthetic COVID-19 guidelines do not, or only briefly, discuss an airway strategy after failed tracheal intubation. Our article identifies and compares pre-pandemic difficult airway guidelines with the recent anesthetic COVID-19 guidelines. We combine the principles from both sets of guidelines and explain the necessary modifications to the airway guidelines, to form a failed tracheal intubation airway strategy in the COVID-19 patient. Valuing, and a greater understanding of, these differences and modifications may lead to greater adherence to the new COVID-19 guidelines.

Abstract
Current evidence suggests that Coronavirus Disease 2019 (COVID-19) spread occurs via respiratory droplets (particles >5 µm), and possibly through aerosol. The rate of transmission remains high during airway management. This was evident during the 2003 severe acute respiratory syndrome epidemic where those who were involved in tracheal intubation had a higher risk of infection than those who were not involved (odds ratio 6.6). We describe specific airway management principles for patients with known or suspected COVID-19 disease for an array of critical care and procedural settings. We conducted a thorough search of the available literature of airway management of COVID-19 across a variety of international settings. In addition, we have analyzed various medical professional body recommendations for common procedural practices such as interventional cardiology, gastroenterology and pulmonology. A systematic process that aims to protect the operators involved via appropriate personal protective equipment, avoidance of unnecessary patient contact and minimalization of periprocedural aerosol generation are key components to successful airway management. For operating room cases requiring general anesthesia or complex interventional procedures, tracheal intubation should be the preferred option. For interventional procedures when tracheal intubation is not indicated, cautious conscious sedation appears to be a reasonable approach. Awake intubation should be avoided unless it is absolutely necessary. Extubation is a high-risk procedure for aerosol and droplet spread and needs thorough planning and preparation. As updates and modifications in the management of COVID-19 are still evolving, local guidelines, appraised at regular intervals, are vital in optimizing clinical management.

Methods: We retrospectively reviewed the cases of parturients diagnosed with severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection disease (COVID-19). Their epidemiologic history, chest computed tomography scans, laboratory measurements, and SARS-CoV-2 nucleic acid positivity were evaluated. We also recorded the patients’ demographic and clinical characteristics, anesthesia and surgery-related data, maternal and neonatal complications, as well as the health status of the involved medical staff.

Results: The clinical characteristics of 17 pregnant women infected with SARS-CoV-2 were similar to those previously reported in non-pregnant adult patients. All of the 17 patients underwent Cesarean delivery with anesthesia performed according to standardized anesthesia/surgery procedures. Fourteen of the patients underwent continuous epidural anesthesia with 12 experiencing significant intraoperative hypotension. Three patients received general anesthesia with tracheal intubation because emergency surgery was needed. Three of the parturients are still recovering from their Cesarean delivery and are receiving in-hospital treatment for COVID-19. Three neonates were born prematurely. There were no deaths or serious neonatal asphyxia events. All neonatal SARS-CoV-2 nucleic acid tests were negative. No medical staff were infected throughout the patient care period.

Conclusions: Both epidural and general anesthesia were safely used for Cesarean delivery in the parturients with COVID-19. Nevertheless, the incidence of hypotension during epidural anesthesia appeared excessive. Proper patient transfer, medical staff access procedures, and effective biosafety precautions are important to protect medical staff from COVID-19.

By January 7, 2020, Chinese scientists confirmed that the outbreak was caused by a novel coronavirus, initially referred to as the 2019-nCoV,2 and recently renamed as severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), and the disease is now termed coronavirus disease 2019 (COVID-19) by the WHO. As of February 20, 2020, more than 75,748 confirmed cases of COVID-19 have been reported in 28 countries (including China) and international conveyance (cruise ship in the Japanese territorial waters), with approximately 99% of cases occurring in mainland China.

While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.

In addition, infection prevention measures need to be implemented to reduce in-hospital transmission. In the operating room, these preparations involve multiple stakeholders and can present a significant challenge. Here, we describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital). These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anesthetic management. Simulation was valuable in evaluating the feasibility of new operating room set-ups or workflow. We also discuss how the hierarchy of controls can be used as a framework to plan the necessary measures during each phase of a pandemic, and review the evidence for the measures taken. These containment measures are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.