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7th April 2020
The Surviving Sepsis Campaign has therefore produced a guideline to support staff in managing critically ill patients with COVID-19. The guideline was produced by a panel of 36 experts from 12 countries and posed 53 questions relevant to the management of patients in the intensive care unit.
Because COVID-19 is a relatively new entity, the group were unable to find much relevant evidence but extrapolated data from other viral infections.
The panel produced a total of 54 statements including four best practice recommendations, nine strong recommendations and 35 weak recommendations but could not make any recommendations for six statements.
The statements covered infection control, laboratory diagnosis and specimens, haemodynamic support, ventilatory support and COVID-19 therapy. Interestingly, four of the statements for which there was no recommendation related to therapy, reflecting the lack of evidence around treatments such as chloroquine which has been suggested an effective therapy.
Another related to the uncertainty of whether to use a helmet or mask although as knowledge of the virus increases, these recommendations are likely to be quickly updated.
The virus can be transmitted through droplet spread and inhalation of infected material, direct contact with an infected individual and from surfaces (fomite transmission). Consequently, healthcare staff who perform procedures such as tracheal intubation are at a high risk of infection themselves.
Due to these risks, a multidisciplinary group recently produced consensus guidelines for managing airway procedures in those infected with COVID-19.
The guidelines are comprehensive and cover several airway procedures including emergency tracheal intubation, tracheostomy and non-invasive ventilation and interested readers should consult the full guideline to review the suggestions for each procedure.
The fundamental principles of the guideline are safety for patients and staff, accuracy, that is, avoiding unreliable, unfamiliar or repeated techniques and finally ensuring that procedures are performed swiftly but without rushing or delay.
The guideline contains a single-page summary that uses emergency tracheal intubation as an example with a step-by-step guide to performing the procedure with examples for good practice, that is, limiting the number of staff present, ensuring staff wear personal protective equipment at all times and touch as little as possible to avoid fomite transmission.
The COVID-19 symptom tracker app identifies the prevalence of known symptoms and maps these to areas of the UK. As only hospital patients are routinely tested, researchers understand very little about the community prevalence and range of symptoms experienced. The app collects anonymised demographic data including age, sex, weight/height, postcode, long-term health conditions and regular use of non-steroidal anti-inflammatories or immunosuppressant therapy.
The app captures prevalence data on the known symptoms of COVID-19 (that is, fever, persistent cough). In addition, because patients record their COVID-19 status if known, it allows researchers to track for other possible symptoms.
The latest analysis is available on the website and interestingly, the data suggests that nearly six in ten infected patients (59%) also lose their sense of smell or taste. Of course, a limitation of the app is that because symptoms are self-reported it is not entirely clear if they are specifically due to COVID-19.
Nevertheless, by tracking the prevalence of known and emerging COVID-19 symptoms, it offers an invaluable insight to those planning how best to manage the pandemic.
Far less is known about how the virus affects the cardiovascular system, but this recent case report in JAMA Cardiology describes the cardiac complications in a patient with COVID-19.
An otherwise healthy 53-year old white woman presented to the emergency department with severe fatigue which had been present for the previous two days. The patient described having had a fever and cough over the previous week but at the time of admission had no other symptoms and was afebrile.
Testing revealed myocardial injury due to increased cardiac troponin levels. The patient was also hypotensive (systolic BP < 90mmHg) and admitted to intensive care and diagnosed with severe left ventricular (LV) dysfunction (reduced LV wall thickness) and acute myopericarditis.
Fortunately, at the time of submission, the authors report that the patient was improving. This appears to be the first recorded incidence of cardiac complications from COVID-19 that might be a consequence of myocyte dissemination of the virus, activation of the immune system and the subsequent onset of heart failure.
5th April 2020
According to the charity, Kidney Care UK, there are almost 30,000 patients requiring either haemodialysis (which is more common) or peritoneal dialysis. NG160 is designed to maximise the safety of patients receiving dialysis while at the same time protecting staff from infection as well as ensuring the best use of NHS resources for dialysis patients should these resources become limited because of COVID-19.
Patient communication
The initial focus of NG160 is to ensure that dialysis staff support patients through effective communication. In particular, the guideline emphasises the importance of supporting patient’s mental wellbeing during this time and to try and alleviate any concerns or anxieties about COVID-19. NG160 directs patients to Kidney Care UK which recently (1 April 2020) updated its advice on COVID-19. This follows the standard government’s recommendation to self-isolate in the presence of a COVID-19 symptoms. This follows the standard government’s recommendation to self-isolate in the presence of a COVID-19 symptoms.
Both NG160 and Kidney Care UK instruct patients to inform their dialysis unit if they feel unwell and to report any relevant COVID-19 symptoms prior to attending their appointment. NG160 stresses the importance of staff informing patients of the need to continue with regular dialysis during the pandemic unless informed otherwise by their clinical team. During the pandemic, NG160 recommends minimising face-to-face contact and that staff make use of either telephone or video consultations. In addition, all non-essential follow-up appointments should be reduced, home delivery services used for medicines and local services for blood tests.
Dialysis appointments
For patients without COVID-19 attending dialysis services, NG160 recommends that they travel alone to appointments and to minimise the time spent in the waiting area. One possible solution proposed in NG160 is that patients remain in their car and that staff send them a text message when ready to commence dialysis.
In cases where patients are either known or even suspected of having COVID-19, it is important to follow specific government guidance on infection prevention and control. NG160 also discusses a course of action for patients who present at appointments with symptoms of COVID-19.
As with all the rapid new COVID-19 guidelines, NG160 recommends that healthcare workers who come into contact with dialysis patients follow the guidance on infection prevention and control.
Patient transport
NG160 emphasises the need to maintain outpatient services schedules for dialysis as much as possible in an effort to prevent deterioration of a patient’s condition. The guideline advises units to cooperate with transport providers to ensure continuity of care and to minimise the potential for cross-infection between patients known or suspected of having COVID-19. Since production of NG160, on 27 March 2020, NHS guidance stated that patients requiring dialysis were one of the priority groups for transport services.
NG160 also advised that where dialysis services cannot be maintained, staff should assess the potential risks and benefits of admitting patients to hospital.
Case ascertainment and cohorting
Given the risk of transmission, NG160 recommends that all patients attending a dialysis unit are screened and triaged for COVID-19. This can be achieved in the reception or waiting area and in addition to enquiring about individual symptoms, staff should also ask whether patients have been in contact with anyone who has a confirmed COVID-19 infection.
To minimise cross-infection, NG160 recommends that patients are dialysed in cohorts based on their COVID-19 status. This should include having separate entrances for infected patients and scheduling appointments to allow sufficient time for cleaning cohorted areas. Patients known to be infected should continue in the COVID-19 cohort for 7 days from the start of symptoms or until they have recovered if this takes longer.
In cases where COVID-19 is strongly suspected, rapid turnaround testing is recommended before dialysis although in many cases it is likely that dialysis is needed before the results of the test are available. NG160 advises that staff assess whether dialysis could be delayed until COVID-19 status is known but equally important that staff also evaluate whether a patient’s symptoms might be due to other causes.
Provision in dialysis units
During the pandemic NG160 advises that all units have agreed protocols in place:
• to restrict unnecessary staff and visitors from the unit
• that explain if or when dialysis treatment may be delayed for new patients
• that risk assessments are agreed with local infection control teams when providing dialysis for COVID-19 patients
• encouraging the uptake of home therapies.
NG160 recognises the need for some patients to be treated in other dialysis units, preferably closer to home, to allow for effective cohorting. If service capacity becomes limited due to an increasing number of COVID-19 cases, NG160 suggests that:
• each patient should be considered on an individual basis and that decisions are made by a multi-disciplinary team
• the reasoning behind any decisions are recorded
• any decisions related to rescheduling are clearly communicated to patients, their families/carers with an explanation of any possible risks and benefits associated with this change.
Leadership and network planning
NG160 underlines the importance of effective planning by a multi-disciplinary operational team and that contingency staff plans are in place. The guideline also emphases the need to work in partnership with local commissioning teams and to nominate an executive lead to support the service. This individual will maintain responsibility for planning, working within regional networks and to review renal plans in line with national guidance on COVID-19.
Liaison with both local and regional providers, will allow oversight of service provision across the region and the ability to assess capacity. Due to the potential disruption of service provision, NG160 advises that patient pathways are established so that patients on dialysis are not admitted to hospitals without dialysis facilities and to enable rapid transport to a hospital if required.
The guideline advises that units enter into discussion with private sector service providers to agree working patterns and adapt these as needed during the pandemic. In such instances, NG160 recommends that independent providers have the capacity to facilitate COVID-19 testing, sufficient technical renal/clinical staff to review patient-staff ratios, risk review the frequency of routine assessments (that is, only doing those that are necessary) and have home delivery drivers.
Patient plans
Due to the potential for limited dialysis NG160 suggests multi-disciplinary teams develop individualised plans for patients to safely reduce dialysis schedules if necessary. NG160 encourages the development of local policies on fluid restriction and the prescribing of potassium binders to enable to the frequency of dialysis to be reduced.
Home dialysis
NG160 recommends that home dialysis services are maintained during the pandemic, ensuring the provision of sufficient staff and equipment. In light of the pandemic, the guideline proposes that units consider the possibility of increasing the level of home dialysis especially for new patients. It also recommends the testing of carers/assistants and patients if they develop any COVID-19 symptoms.
The guideline is available online and interested readers should check for any relevant updates.
2nd April 2020
In recent years, opioid prescribing for acute pain by US dentists has increased but is this the most effective approach? A recent study attempted to answer this question.
The prescribing of opioids in the US has become a major public health emergency. According to the Centre for Disease Control (CDC), in 2018, there were 67,367 drug overdose deaths in the US, of which 69% (46,802) were attributed to opioids.1 The prescribing of opioids has been rising in other countries and while comparative figures for opioid-related deaths in the UK are significantly lower than the US, in 2018, opioids were implicated in 51% of the 4,359 drug-related deaths in England and Wales.2
In 2016, the CDC issued advisory guidelines for primary care practitioners which sought to address the prescribing of opioids.3 While these were mainly directed at the management of chronic rather than acute pain, dentists were not considered a part of the target audience. Nevertheless, dentists in the US prescribe a huge amount of opioids.
A recent comparative study of opioid prescribing by US and English dentists, found that in 2016, 22% of all US dental prescriptions (nearly 11.5 million) were for opioids. In contrast, over the same period of time, only 0.6% (28,082) of English dental prescriptions were for opioids.4 Other work has also revealed how the proportion of opioid prescriptions in the US issued by dentists to opioid-naïve patients increased by nearly 16% between 2010 and 2016.5
A potential concern when prescribing to opioid-naïve patients is the risk of dependence. In a study of women prescribed opioids after surgery, it was found that 6% of patients continued to use opioids 90 days after surgery6 and similar risk of dependence has been observed among patients prescribed opioids after a dental procedure.7 In their defence, dentists could point to a systematic review in 2015 which found that the most effective analgesic combination after third molar extraction (i.e. Wisdom teeth removal) was a combination of oxycodone and ibuprofen.8
But can the results of the 2015 review be generalised to other procedures such as a routine extraction? A new study published in JAMA set out to compare the pain and satisfaction scores among patients prescribed either opioids or non-opioids after a tooth extraction.9 Given the high level of opioid prescribing by dentists for post-extraction pain relief, this was a quality improvement study designed to test the hypothesis that the same or similar levels of pain relief offered by opioids could be achieved with non-opioid alternatives.
The study included 329 patients, of which 47% underwent surgical extraction, in which an incision was required to gain access to the tooth and 53% who underwent a routine extraction where no such incision was required. Opioid prescriptions were given to 109 patients after a surgical extraction and 86 after a routine extraction. Non-opioid treatments included non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen, naproxen) or paracetamol and all patients received a follow-up telephone consultation within six months of their procedure to assess post-extraction pain relief and satisfaction with pain management.
The primary outcome was self-reported pain in the first week after the dental extraction. Pain was categorised as no pain, minimal pain, moderate pain and severe pain. Satisfaction with pain management was measured on a 10-point scale ranging from extremely dissatisfied (1) or extremely satisfied (10).
What was particularly interesting was the finding that irrespective of the type of procedure, patients given an opioid reported worse pain in the week following extraction compared to those given a non-opioid. However, there were no differences in satisfaction scores between opioid and non-opioid users, with both groups achieving a median score of 9. While patients in both the opioid and non-opioid group did report using additional analgesics after their extraction, there were no significant differences between them.
The results of this study provide clear evidence that when managing the acute pain associated with a dental extraction, opioids offer less relief than non-opioid alternatives. This finding resonates with the conclusions of a systematic review which found that the most effective treatment for acute dental pain is a combination of ibuprofen and paracetamol.10
The review also noted that the ibuprofen/paracetamol combination was superior to any opioid medication. But will the results of this study lead to changes in the prescribing habits of US dentists and help to lessen the opioid crisis? Unfortunately, one potential barrier is recent guidance from the American Dental Association (ADA) which, rather than advocating that opioids are not used to manage acute pain, simply recommends that opioid prescriptions are restricted to no more than seven days.11
Though the evidence clearly demonstrates that opioids are inferior to non-opioid alternatives for acute dental pain, with the ADA guidance still endorsing short-term prescribing of opioids, whether US dentists curtail their prescribing remains to be seen.
References
This compilation of strategies, experiences and precautions, published ahead of print in The Journal of Nuclear Medicine, is intended to support nuclear medicine clinics as they make decisions regarding patient care.
Clinicians from Africa, Asia, Australia, Europe and North America provided summaries of the steps their individual hospitals and clinics have taken to combat the COVID-19 pandemic. According to editorial author, Ken Herrmann, MD, MBA, chair of nuclear medicine at the University of Duisburg-Essen, Essen, Germany, the most common steps taken by clinics have been to triage patients upon arrival, reduce elective nuclear medicine studies, improve hygiene practices and establish rotations of medical personnel to create back-up teams should a staff member become infected.
For patients undergoing essential nuclear medicine procedures, incidental findings can suggest signs of COVID-19, according to editorial author Domenico Albano, MD, nuclear medicine physician at the University of Brescia and Spedali Civili Brescia in Italy. Reporting on local experience in a region with high COVID-19 prevalence, Albano and colleagues found six out of 65 asymptomatic PET/CT patients and one of 12 radioiodine patients showed signs of interstitial pneumonia. Five of the seven patients were confirmed to have COVID-19; the remaining two did not receive immediate testing but underwent quarantine and careful monitoring.
“Our observations show that it is mandatory for healthcare personnel to employ hygienic measures, minimise patient contact and optimise distance, and use protective equipment for general clinical services in regions with high COVID prevalence,” said Albano. “It is also important to consider potential COVID-19 related findings during reading, and to report such findings to the patient and his referring physicians immediately, for appropriate action.”
Of particular interest to the nuclear medicine community is the safety of performing ventilation/perfusion studies. “Previous literature has documented a small degree of leakage of the aerosol from the closed delivery system into the room with the potential for expired air and aerosolised secretions to contaminate personnel within the imaging suite,” noted Lionel S. Zuckier, MD, MBA, FRCPC, editorial author and chief of the division of nuclear medicine at Montefiore Medical Center and Albert Einstein College of Medicine in Bronx, New York. “In addition, patients frequently cough following inhalation of the radiopharmaceutical, which may further expose nuclear medicine workers to aerosolised secretions.”
Given these circumstances, ventilation/perfusion studies have the potential to result in aerosolised secretions that can contribute to the spread of COVID-19. Zuckier and colleagues recommend eliminating the ventilation portion from lung perfusion/ventilation scans to reduce the risk of spreading COVID-19.
Additional steps taken by clinics to combat the spread of COVID-19 include limiting or cancelling research studies and scheduling symptomatic patients needing essential studies for the end of the day (allowing for thorough cleaning after the study). Some clinics have conducted refresher courses in infection control management and basic emergency management, while others have stressed the need for kindness and consideration in this unprecedented time.
Concerns were also voiced by nuclear medicine clinics around the world regarding potential nuclear reactor production restrictions and international travel limitations. Strategies to tackle these issues are being addressed by nuclear medicine and molecular imaging society leadership worldwide.
“These are difficult times; none of us has ever experienced anything like the current pandemic,” remarked Johannes Czernin, MD, JNM editor-in-chief and chief of the Ahmanson Translation Imaging Division at the David Geffen School of Medicine at the University of California, Los Angeles in California. “We thank the hundreds of thousands of health care workers worldwide who have not hesitated for a moment to come in and do their job at times of great personal risk. These are selfless people who help and support each other; cover for each other; volunteer to step in and up as needed.”
1st April 2020
The plan, which focuses on eight critical elements: “stuff,” “staff,” “space,” “systems,” “sedation,” “separation,” “communication” and “equity”, and is published in the A COVID-19 palliative care pandemic plan.
Palliative care is a human right for patients. “The current COVID-19 pandemic will likely strain our palliative services beyond capacity,” says Dr James Downar, the head of the Division of Palliative Care at the University of Ottawa and a palliative care physician at The Ottawa Hospital and Bruyère Continuing Care. “We advise acting now to stockpile medications and supplies used in palliative care, train staff to meet palliative care needs, optimise our space, refine our systems, alleviate the effects of separation, have critical conversations, and focus on marginalised populations to ensure that all patients who require palliative care receive it.”
“Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill,” writes Dr Downar with coauthors. “Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity.”
The plan is an expansion of a framework developed by the US Task Force on Mass Casualty Critical Care for events with large numbers of injuries and casualties, with the addition of the last four elements, sedation, separation, communication and equity.
“Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right,” the authors conclude.
31st March 2020
This evidence is enabling several international partners, including the Norwegian Institute of Public Health (FHI) and NHSX, a joint unit comprised of teams from NHS England and the UK’s Department of Health & Social Care, to assess the feasibility of developing mobile apps for instant contact tracing in record time. If rapidly and widely developed, these mobile apps could help to significantly slow the rate of transmission, and support countries to emerge from lockdowns safely, as restrictions are gradually eased.
Professor Christophe Fraser from Oxford University’s Big Data Institute, Nuffield Department of Medicine, a lead author on the Science paper explains, “We need a mobile contact tracing app to urgently support health services to control coronavirus transmission, target interventions and keep people safe. Our analysis suggests that about half of transmissions occur in the early phase of the infection, before you show any symptoms of infection. Our mathematical models also highlight that traditional public health contact tracing approaches provide incomplete data and cannot keep up with the pace of this pandemic.”
The project is co-led by Dr David Bonsall, senior researcher at Oxford University’s Nuffield Department of Medicine and clinician at Oxford’s John Radcliffe Hospital, who explains “The mobile app concept we’ve mathematically modelled is simple and doesn’t need to track your location; it uses a low-energy version of Bluetooth to log a memory of all the app users with whom you have come into close proximity over the last few days. If you then become infected, these people are alerted instantly and anonymously, and advised to go home and self-isolate. If app users decide to share additional data, they could support health services to identify trends and target interventions to reach those most in need.”
The authors argue that a mobile app can reduce transmission at any stage of the epidemic, in countries or regions where the epidemic is just emerging, at the peak of the epidemic, or to support a safe transition out of restricted movement or lockdown. It could also help to reduce the serious social, psychological and economic impacts caused by widespread lockdowns. Critically, the researchers suggest a mobile app can help slow the spread of infection until vaccines and antiviral treatments become widely available.
Prof Fraser explains, “A contact tracing app can foster good citizenship by alerting people at risk, it can also help ease us out of confinement If we know we’ve not been in contact with anyone infected we can leave home safely, whilst still protecting our loved ones and avoiding a broader resurgence of coronavirus in our community.”
Given the level of infection across much of Europe, the team believe ongoing development of a mobile app partnership across the union would massively reduce transmission and avoid a resurgence in the number of cases, providing an opportunity for all citizens using mobile contact tracing apps to contribute towards ending the epidemic. An app strategy could also be used by low- and middle-income countries, earlier in the epidemic, to rapidly control transmission and get ahead of the epidemic now.
The Oxford team highlights that the mobile contact tracing app should still be combined with isolation of cases, tracing and quarantine of contacts, physical distancing, scaled-up diagnostic testing, decontamination and hygiene measures.
As Dr Bonsall explains “If the mobile app is widely adopted in any country, and combined with other critical interventions such as physical distancing and widespread testing, our models suggest the epidemic could be brought under control. This app is a tool for each and every person affected to contribute towards protecting their health services, supporting vulnerable people and simultaneously gradually releasing communities out of extended quarantine.”
Today’s Science study highlights the importance of rigorous ethical standards underpinning the successful and appropriate use of mobile phone technology in addressing the coronavirus pandemic; including a number of ethical requirements needed to foster well-founded public trust and confidence. Professor Michael Parker, Director of the Wellcome Centre for Ethics & Humanities and one of the paper’s authors, highlights, “With transparent and inclusive ethical oversight to ensure genuine public trust, it is possible to both save lives and protect civil liberties. The app should be opt-in, provide secure data storage and privacy protection, and be informed by public and user engagement at every stage of implementation. With these guarantees and, if widely installed by users across a country or regional bloc, a mobile app could even help to end the epidemic.”
As mobile apps launch over the coming weeks and months, the Oxford research team urges people to support official apps, developed by trusted institutions, and their partners, such as the mobile contact tracing apps under advanced assessment in several European countries. Professor Fraser concludes, “Our hope is to support communities with life-saving information as the pandemic worsens and help to release countries from large-scale isolation. The maths is clear: the more people that use a contract tracing app the better chance we have of getting ahead of this epidemic and eventually stopping it in its tracks. If a country reduces the epidemic growth rate to below zero, the epidemic will rapidly decline and eventually stop. Together we can make this possible.”
This is according to a review published in JAMA Cardiology by experts at The University of Texas Health Science Center at Houston (UTHealth).
Experts have known that viral illnesses such as COVID-19 can cause respiratory infections that may lead to lung damage and even death in severe cases. Less is known about the effects on the cardiovascular system.
“It is likely that even in the absence of previous heart disease, the heart muscle can be affected by coronavirus disease,” said Mohammad Madjid, MD, MS, the study’s lead author and an assistant professor of cardiology at McGovern Medical School at UTHealth. “Overall, injury to heart muscle can happen in any patient with or without heart disease, but the risk is higher in those who already have heart disease.”
The study authors explained that research from previous coronavirus and influenza epidemics suggest that viral infections can cause acute coronary syndromes, arrhythmias, and the development of, or exacerbation of, heart failure.
In a clinical bulletin issued by the American College of Cardiology, it was revealed that the case fatality rate of COVID-19 for patients with cardiovascular disease was 10.5%. Data also points to a greater likelihood that individuals over the age of 65 with coronary heart disease or hypertension can contract the illness, as well experience more severe symptoms that will require critical care.
According to the study authors, critical cases are those that reported respiratory failure, septic shock, and/or multiple organ dysfunction or failure that resulted in death. “It is reasonable to expect that significant cardiovascular complications linked to COVID-19 will occur in severe symptomatic patients because of the high inflammatory response associated with this illness,” said Madjid.
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