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Description : Check out this medical presentation on Anticoagulant, which is titled "ICU care for a patient with hypercoagulation", to know about ICU care for a patient with hypercoagulation, techniques to treating respiratory failure, and precautions for OB care during the COVID-19 crisis.

Tags : Anticoagulant, ICU care, hypercoagulation, respiratory failure, OB care, COVID-19 crisis

Published on : May 25, 2021 | Views : 1701 | Downloads : 1

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COVID-19 Town Hall Webinar April 16, 2020
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Housekeeping For this broadcast, your camera and microphone have been disabled. We encourage you to interact with other participants in the Chat, located at the bottom of the broadcast window. Submit questions to the panel using the Q&A box at the bottom of the broadcast window, not through the Chat. If you have technical issues, please close your browser and restart the webinar – or perhaps move closer to your router. We are recording this broadcast today and will be adding the full video to the ASA website to view on demand or share with your colleagues within the next 24-48 hours. asahq.org | apsf.org
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Disclaimer asahq.org | apsf.org As a reminder, the items we discuss today are provided for informational purposes only and do not constitute medical or legal advice. As always, you should consult with your own medical and legal counsel.
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Learning Objectives At the end of this event, learners will be able to: Describe ICU care for a patient with hypercoagulation Identify techniques to treating respiratory failure Discuss precautions for OB care during the COVID-19 crisis www.asahq.org/townhalls asahq.org | apsf.org
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Welcome, Anesthesia Community Anesthesia Care Team: Anesthesiologists, Anesthesiologist Assistants, Nurse Anesthetists, Anesthesia Techs, Anesthesia Administrators and Executives American Society of Anesthesiologists Anesthesia Patient Safety Foundation Society of Critical Care Anesthesiologists Society of Critical Care Medicine Hospital and health system leaders asahq.org | apsf.org
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Anesthesia Machines as ICU Ventilators and ICU Patient Management Training New and frequently updated guidance on converting anesthesia gas machines and fresh gas flows. Detailed instruction and a quick reference guide available online and in PDF form. Created in collaboration with ASA/APSF. www.asahq.org/ventilators Additional updated resources and training for managing COVID patients in the critical care setting. Created in collaboration with ASA/APSF/SOCCA/SCCM. www.asahq.org/CAESAR asahq.org | apsf.org
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Anesthesia Machines as ICU Ventilators Hotline Help increase the availability of ventilators for the ICU setting Get instruction and guidance to use anesthesia machines as ventilators Call agents available to provide web-based resources 24/7 Physician experts on call daily from 6 a.m. – 10 p.m. ET 1-800-224-1001 asahq.org | apsf.org
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Special Hotel Deals and Discounts Member-exclusive offers and discounts from American Express, Hilton, Marriott and Hyatt. www.asahq.org/hotel-discounts asahq.org | apsf.org
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Economic Relief and Drug Shortages Economic Relief $30 billion in grants was released to physician practices Additional loans from Small Business Administration issued Continued advocacy (See "Late-Breaking Developments" on ASA website https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information) Addressing Drug Shortages FDA approved 2020 aggregate production quota increase of 15% for certain opioids Asked FDA to appropriately extend expiration dates Partnering with ASHP on guidance to avoid unnecessary drug wastage asahq.org | apsf.org
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Online Education Free to AA Student Members Bridge the gap in planned clinical learning with free online education Anesthesiologist Assistant programs can enroll their students, if they are ASA members, in free online education courses through June 30, including: Anesthesia SimSTAT - Powerful, realistic online simulation training ACE-CAA Plus 19 Patient Safety modules – always free! Program leaders please contact Sarah Braun: s.braun@asahq.org asahq.org | apsf.org
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Incredible Progress – And More to Come asahq.org | apsf.org
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Share Your Stories asahq.org | apsf.org How has COVID-19 changed your daily life and practice? What poignant or uplifting patient care situations have you experienced? How are you leading as an anesthesiologist? www.asahq.org/covidstories
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asahq.org | apsf.org Panel Participants
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COVID Vent Management Mark Caridi-Scheible, M.D. Emory Critical Care Center, Atlanta, GA
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Introduction & Objectives Anesthesiology Critical Care Attending Emory University Hospital Team member, Best Practices Committee for Emory system Today: Ventilation and oxygenation strategies in COVID for intubated patient only Not today: Oxygenation strategies pre-intubation Timing of intubation asahq.org | apsf.org
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The Disease COVID waits for no one Slow, extended plateaus with rapid, unpredictable transitions over hours Prodrome Silent hypoxia (O2 2-8L, comfortable, floor phase) Tachypnea may be early warning Struggling (O2 10-15L, increasingly tachypneic +/- anxiety&SOB, worse CXR) Increasing presentation, some recover from this phase but fewer, must be in ICU Respiratory Failure (O2 > 15L) HHFNC or Intubation Recovery or MOSF/sudden death Encephalopathy, atypical hypoxic failure (normal compliance, not really ARDS), mild AHI, variable but common AKI, hypercoagulability, difficult & occult secretions) Sudden death (hyperinflammatory/myocarditis picture), hypercoagulability asahq.org | apsf.org
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Patients & Statistics At single hospital 60 known positive patients that were critically ill Wide age range but relatively few < 40 yo Variety of co-morbidities including HTN, asthma, sarcoid, transplant, myxedema, CAD, morbid obesity, HF Approx 90-95% required intubation Relatively few proning, paralysis, flolan Intubation duration range 7 days to 3 weeks 3 VV-ECMO Most getting extubated, about 5% heading to trach 20% mortality for ICU admits Most consistent with co-morbid disease – esp immunosuppressed, advanced age Several deaths that seem to have been associated with cardiac or PE As weeks go on, mortality rising due to: Increasing number presenting sicker (self-isolated) and requiring intubation immediately Accordingly increased number of vent days per patient Superinfection, PE, CVA Good supportive care remains only known effective therapy asahq.org | apsf.org
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Early Experiences Approached like ARDS PEEP (high), paralysis, proning, epoprostenol High MAP (APRV, IRV) Low volumes But noticed: Compliance usually preserved (but not always) Evidence of overdistention compliance worsened as peep pushed to high end of vital capacity Several pneumothoraces Hemodynamic instability Dyssynchrony more pronounced Highly variable response to proning, peep, paralysis, inhaled dilators asahq.org | apsf.org
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COVID Lung Some conflicting recommendations, but good overall explanations: ESICM Webinar: How to ventilate in COVID-19 April 2, 2020, Wong https://www.esicm.org/blog/?p=2744 Gattinoni et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? https://www.esicm.org/wp-content/uploads/2020/04/684_author-proof.pdf asahq.org | apsf.org
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COVID Lung – 2 Phenotypes Normal Compliance Gattinoni Type “L” V/Q mismatch 2/2 dysregulated hypoxic vasoconstriction & inflammation Relatively low PAP Low lung weight Low recruitability Low Compliance Gattinoni Type “H” V/Q mismatch 2/2 shunt through non-aerated consolidations Increased PAP Increased lung weight High recruitability asahq.org | apsf.org
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ARDS Lung vs. Non-ARDS COVID Lung asahq.org | apsf.org A Comprehensive Review of Prone Position in ARDS. Richard H Kallet
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Ventilation Strategy – ARDS Phenotype Low compliance Usual ARDS Management PEEP Ladder APRV, IRV Low tidal volumes Paralysis (cognizant of shortages) Proning +/- Paralysis Inhaled pulmonary vasodilators (cognizant of shortages) Sedation/paralysis as required for synchrony & compliance Avoid Miduri steroids as long as able asahq.org | apsf.org
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Vent Strategy – High Compliance Phenotype Normal compliance Minimize PEEP Keep to 8-12 as able, wean first as able Favor increasing FiO2 first Recruitment maneuvers as needed without PEEP increases If able, use optimal peep methods (P0.1, Opening P, esoph manometry, etc) Allow normal tidal volumes Mindful of P-SILI asahq.org | apsf.org
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Vent Strategy – High Compliance Phenotype Normal compliance Inhaled pulmonary vasodilators May be more effective in this group Proning May not be as effective in this group Consider not being first line tx given number of people required/safety & sedation requirements Paralysis Does not seem to be helpful except as rescue for dyssynchrony (bolus dose) No role for steroids Mode discussion requires some context asahq.org | apsf.org
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Dyssynchrony in High Compliance Group Multifactorial Profound encephalopathy Air hunger due to inflammation Coughing and tenacious secretions Mode inconsistent with phenotype Signs High peak pressures Belly breathing High negative pressures as evidenced by CVP or other hemodynamic swings Agitation Sudden desaturations Coughing Tachypnea asahq.org | apsf.org
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Dyssynchrony What the patients want High flow rates, short I-time Variable tidal volumes High tidal volumes Mobilize mucous High minute ventilation (appropriately or not) Synchrony complicated by Patient-Self Induced Ventilatory Injury (P-SILI) High negative pressures and pulmonary edema Volutrauma Sedation & Paralysis Desire to minimize d/t downstream effects and shortages Provider comfort and skill adjusting vent asahq.org | apsf.org
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Mode and Synchrony – Staged Approach Acute decompensation: bolus paralytic, get control Secretions: good pulmonary hygiene regimen for everyone (HTS, avoid anticholinergics, chest PT as needed) Vent mode: PCV likely best, monitor compliance Allow normal tidal volumes Avoid fixed flow (VC) PC-VG modes may work but may oscillate Adjust I-time to match desired exhalation time If remains dyssynchronous, high negative pressures or high tidal volumes Increase level of sedation judiciously If already unresponsive (RASS -4 or 5) and appears reflex driven, consider bolus paralysis If requires multiple bolus paralysis despite all else, then consider continuous Keep trying tho to return to above asahq.org | apsf.org
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Non-vent considerations, any phenotype Micro or macrovascular thrombi May be contributing to both hypoxia and hypercarbia Consider addressing with anti-coagulation (next presentation) asahq.org | apsf.org
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Extubation Pulmonary mechanics and gas exchange resolve before encephalopathy Potentially high reintubation rate if too aggressive extubation Deconditioning is rapid Plan on extubation to HHFNC or NRB for period of time asahq.org | apsf.org
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Final thoughts Supportive care #1 tx It will be unfamiliar territory It continues to be worth it asahq.org | apsf.org Photos by Christina Creel-Bulos, M.D., Critical Care Fellow
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Anticoagulation and Monitoring Justin N. Tawil, M.D., FASA Assistant Professor of Cardiothoracic and Critical Care Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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Disclosures No conflicts of interest My direct care of COVID patients has been those on ECMO
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Summary Known COVID-19 specific hematology issues Review common anticoagulants Coagulation and anticoagulant monitoring pitfalls Treatment recommendations What my team is doing Conclusions Google Image
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Coronavirus Coagulopathy Septic inflammation and DIC common SARS and MERS† Acute Phase Reactants: fibrinogen, factor VIII, thrombocytosis Disseminated Intravascular Coagulation (DIC): clotting and lysing Low fibrinogen & platelets Elevated PT/PTT/d-dimer Coagulopathy is common in sick COVID-19 patients 50% of non-survivors; 7% of survivors‡ DIC: 71% non-survivors; 0.4% of survivors∆ Clotted fingers/toes without high dose pressors ‡Zhou F, et al. "Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study." The Lancet (2020). ∆Wang D, Hu B, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama. 2020 Feb 7. †Giannis D, Ziogas IA, Giannic P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virology.
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COVID-19 Hemorrhagic Phenotype Autopsy reports of pulmonary hemorrhage confirmed in the US Thrombocytopenia & low fibrinogen Associated with poor outcomes Late stage of DIC? Overt bleeding rates unknown Image from: Fox SE, et al. Pulmonary and Cardiac Pathology in COVID-19: The First Autopsy Series from New Orleans medRxiv 2020.04.06.20050575
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COVID-19 Thrombophilic Phenotype Limited autopsy data vary thrombosis and microthrombi Common to have dialysis, CVL & ECMO clotting Case reports of extensive thrombosis Case series of PE/DVT Chinese “studies” questionable and often no ppx Rates of thrombosis unknown Dutch ICU study shows 31% composite thrombosis On ppx DVT/PE ~27% Stroke ~ 3% Klok FA, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis Research (2020).
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Risks of Anticoagulation Bleeding (2-5%) ICH Pulmonary Procedure related (frequent line placement) Retroperitoneum Falls & Foley trauma Heparin Induced Thrombocytopenia UFH ~ 1% LMWH ~ 0.5% Bleeding Clotting Anticoagulation
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Unfractionated Heparin (UFH) Facilitates Anti-Thrombin (AT) Increases AT function 1000x Functions in plasma, not clots Clearance is temperature, dose and renal dependent Reversal agent protamine Unfractionated Heparin monitoring is complex Annich GM. Extracorporeal life support: the precarious balance of Hemostasis J Thromb Haemost. 2015 Jun;13 Suppl 1:S336-42 Dosing PPX: 5,000 – 7,500 units q 8-12h Tx: 4-30 units/kg/hr
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Low Molecular Weight Heparin (LMWH) Enoxaparin & Dalteparin Primarily blocks Xa (AT) Benefits: faster to tx, no infusion, PTT and anti-Xa more reliable Comparable bleeding risk to UFH Reduce dosing for GFR < 30 Increase dosing in BMI > 40 Reversal with protamine partially effective Dosing (adjust for GFR and obesity) PPX: Enoxaparin 30-40mg q 24h Dalteparin 2,500 – 5000 Units/24h Tx: Enoxaparin 1mg/kg q 12h Dalteparin 120 units/kg q 12h
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ARDS and Anticoagulation Image from : Fox SE, et al. Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans medRxiv 2020.04.06.20050575 ∏: Hardaway RM, Harke H, Williams CH. Fibrinolytic agents: a new approach to the treatment of adult respiratory distress syndrome. Adv Ther. 1994;11:43–51. Blue perialveolar fibrin deposits Pre-COVID Tissue Plasminogen Activator (TPA) in ARDS increases PaO2∏ Beth Israel COVID TPA trial 25mg (over 2 hours) followed by 25mg / 22 hours Responders continued on heparin COVID Hope Trial Inhaled Heparin + NAC
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Other Agents Direct Thrombin Inhibitors Bivalirudin & Argatroban HIT and heparin resistance PTT dependent monitoring Inhibit IIa No reversal agents Act in plasma and clot Expensive ($400-4000 per day) Direct Oral AntiCoagulants (DOAC) Direct Xa inhibitors Minimal monitoring needed Can be used for ppx or tx Apixaban reversal Preferred over coumadin
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Coagulation and Monitoring Activated Clotting Time (ACT) ACT is poorly associated with heparin dosing, bleeding, clotting All ACT is not the same Many devices (ACT, ACT Plus, ACT Hemacron …) “Normal” range is different with each device Confounders: hemodilution, anemia, factor deficiency, hypothermia, low fibrinogen, platelet function and number, d-dimer PTT and Anti-Xa testing are preferred to ACT
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Anticoagulation Monitoring in COVID TLDR: Anti-Xa heparin monitoring is better. Non-heparin PTT confounds in COVID are strong and variable. Partial Thromboplastin Time (PTT) Intrinsic pathway (VIII,IX,X,XI,XII) No standard lab technique 300+ protocols Goal 1.5-2.5 x normal/baseline No standard control Weak correlation to heparin dosing Reduced PTT High levels of factor VIII and fibrinogen Prolonged PTT Anemia/polycythemia, low fibrinogen, d-dimer, CRP, liver dysfunction, low factor levels, low or dysfunctional platelets, lupus, tube filling errors, delayed processing, diurnal changes, sample transport temp… Anti-X Inhibition of Xa Pure heparin/AT test Gold standard (expensive, availability) Goal 0.3-0.7 IU Confounds LOWER reported values: Triglycerides> 350mg/dl, Total bilirubin > 6 mg/dl, hemolysis, post tPA Cause OVER dosing of heparin No effect from fibrinogen & platelets asahq.org | apsf.org Arnouk S, et al. Evaluation of anti-Xa and activated partial thromboplastin time monitoring of heparin in adult patients receiving extracorporeal membrane oxygenation support. ASAIO Journal 66.3 (2020): 300-6.
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Society COVID Recommendations Limited data to alter generic ICU ppx ASA Critical Care Committee Member Experience Full range of tx International Society on Thrombosis and Haemostasis All COVID without contraindications: ppx LMWH American Society of Hematology Monitor for DIC LMWH ppx hospitalized COVID (unless low plt/ fibrinogen) ***Dose adjustment for obesity and renal failure*** Full anticoagulation only for documented thrombus
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What my team is doing now Non-surgical patients Floor: ppx LMWH daily ICU: ppx LMWH q 12h D-dimer > 5 mcg/ml or line issues Consider therapeutic case by case Anti-Xa q 6-24h PTT & TEG PRN or daily ECMO No changes to antiplatelet Aspirin 81mg daily Hold if plts <50 and TEG MA <50 Previously targeting Xa = 0.21-0.35 COVID patients are clotting oxygenators UFH Xa 0.3 – 0.7 Daily TEG R-time (10-16s) asahq.org | apsf.org
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Take home points Inflammatory surge is variably associated with hypercoagulable state Understand your lab test & patient as you interpret results Inflammation activates Tissue Factor and Compliment pathways Anticoagulation initiation, drugs & goals should be patient specific Anti-Xa based monitoring more accurately reflects heparin effect in COVID Caution with dysfunctional liver or platelets PTT guided anticoagulation is problematic in COVID Increased with elevated d-dimer, DIC and CRP Decreased with high levels of factor VIII, and high fibrinogen Hematologic societies remain skeptical of empiric anticoagulation
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Thank You Mary Dale Peterson, M.D. & George Williams, M.D. ASA CCM Committee Lisa Baumann Kreuziger M.D. and Joel Feih, PharmD All of you fighting the good fight
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References Arnouk S, et al. Evaluation of anti-Xa and activated partial thromboplastin time monitoring of heparin in adult patients receiving extracorporeal membrane oxygenation support. ASAIO Journal 66.3 (2020): 300-6. Fox SE, et al. Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans medRxiv 2020.04.06.20050575 Giannis D, Ziogas IA, Giannic P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virology Hardaway RM, Harke H, Williams CH. Fibrinolytic agents: a new approach to the treatment of adult respiratory distress syndrome. Adv Ther. 1994;11:43–51. Klok FA, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis Research (2020). Levine MN, Hirsh J, Gent M, et al. A randomized trial comparing activated thromboplastin time with heparin assay in patients with acute venous thromboembolism requiring large daily doses of heparin. Arch Intern Med. 1994;154:49-56. Raschke R, Hirsh J, Guidry JR. Suboptimal monitoring and dosing of unfractionated heparin in comparative studies with low-molecular-weight heparin. Ann Intern Med. 2003;138:720-723. Wang D, Hu B, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama. 2020 Feb 7. Zhou F, et al. "Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study." The Lancet (2020).
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Management strategies for the parturient during the COVID-19 pandemic McCallum R. Hoyt, M.D., M.B.A. Chair, ASA Committee on Obstetric Anesthesia
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asahq.org | apsf.org OB Anesthesia Committee Survey Negative pressure LDRS and/or ORs Screen or test all parturients Use of N95 masks How many PUIs and COVID-19 positive parturients
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General Principles Limit the number of caregivers in the room Only the most experienced Negative pressure rooms? Identify and prepare an OR for COVID use Minimal Equipment Airway kits Medications brought in for the case Simulate: Donning and doffing Workflow for a general anesthetic Transport to another area
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Policies
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Some form of prescreening should occur Phone call for elective inductions and sections Screening questions at arrival point on labor floor Testing? NEJM Correspondence April 13, 2020 Should a patient have an elective cesarean delivery because she has COVID? American College of Obstetricians and Gynecologists (ACOG) https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyn-obstetrics Preassessment
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Labor Management Early epidural Most experienced Limit interactions Same person interviews and places Replace epidural if more than one adjustment is necessary Limit equipment Take what you need into the room “Runner” to help with don/doff and get missing/extra supplies N95?
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OR cases under neuraxial Droplet and contact precautions per CDC Full don with N95 in case of need to intubate One provider? Runner available to come in if needed Dressed in full gear except mask and face shield Face mask over patient throughout case Cover over patient during transport Recovery and transport strategies
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OR cases under GA Droplet and contact precautions per CDC Full don with N95 DO NOT TAKE SHORTCUTS Two anesthesia team members with runner nearby Runner dressed in full gear except mask and face shield Three now committed to the case so consider back-up strategy Face mask over patient and cover during transport to and from Intubate as would in surgical OR Recovery and transport strategies
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Earlier Questions NSAID use? Presence of fever? Thrombocytopenia? N2O use? Antiemetics? Dexamethasone? The pregnant anesthesiologist
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Thank You and Be Well Your participation in this webinar enables you to claim CME credits at www.asahq.org/covid19cme Replay and slides will be available at www.asahq.org/townhalls within 24 hours. Please share with your colleagues who weren't able to participate tonight. Additional and ongoing COVID-19 resources at www.asahq.org/covid19info asahq.org | apsf.org