Author: M Velia Antonini

Support & join ECMOCARD!

A global crisis needs a global response and global collaboration. In an unknown disease, ECMOCARD Study Group is coordinating with 26 countries across 4 continents to share data real-time.
With these data, we will use Artificial Intelligence to produce machine learning and feed back decision support to clincians who are currently “driving blindfold” in this entirely new and poorly understood condition.
Our best current asset is shared experience and global data to guide treatment today and tomorrow. But research needs to be supported!

Here a letter to the Political Leaders of Australia, signed by Professor John Fraser, Professor Robert Bartlett and by by all the regional Leads of the study (full list in the dedicated picture).
“The Covid-19 pandemic is an unprecedented global situation. The WHO calculates that between 60 and 80 per cent of the world population will be infected. This will place an overwhelming burden on hospitals in general, but specifically on intensive care resources. Never before have we seen this disease, nor its magnitude. We have no data on how best to care for our patients – specifically your parents. Without data, we are driving blindfold at 100 Km/h – with your relatives ir the vehicle.
Australian medical leaders realised the urgent necessity to gather key treatment information They stood up to this challenge – and created “ECMOCARD ” – the only global study to gather data or the ICU management of the sickest and most vulnerable patients. It is a great example of the globa medical community working as one- for the good of the global patients.
In representing the global ICU community, we respectfully and humbly ask the Australiar Government to align themselves with their medical leaders and take the leap. Support of the ECMOCARD global collaboration can assist the global community.
Australian Political Leaders should stand shoulder to shoulder with their Medical Leaders – for the sake of us all.

In these pictures, a list of the International ECMOCARD Study regional Leads (all of the have co-signed the letter), and a map with the active sites: the list is continuously updated, as more and more centers, in more Countries, are being involved, and join the study group.

We currently have 104 collaborating centres, and a further 7 sites anticipated to come on board in the near future. This is a fantastic effort on behalf of all collaborating sites and speaks volumes of the importance and clinical relevance of the data we are collecting (Sites map is superimposed to the online dashboard for tracking worldwide spread of the Coronavirus has been built & is regularly updated by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University; the map is freely available and constantly updated link).

Recently Professor John Fraser released an interview to Norman Swan for ABC’s Health Report and, discussing how intensive care specialists will deal with the influx of patients with SARS-CoV-2 infection. “We’ve got a global responsibility for our global community,” Professor Fraser said. Details about interview & full video here.

Airways in COVID-19

Managing airways in confirmed/suspected COVID-19 patients

Patients infected by SARS-CoV-2 Coronavirus may develop severe pneumonia induced by COVID-19, eventually requiring invasive mechanical ventilation to support gas exchange; in these subjects, endotracheal intubation needs to be performed. Given the potential for aereosol/droplets generation, this procedure is one of the highest-risk moments for spreading the disease, and any effort should be made to minimize this risk, maximizing safety of any of the healthcare providers performing intubation, or involved in, and patients’ safety too. Here a collections of free open access checklists, algorithms & infographics focused on this current & complex topic. All of these are reproduced with permission (random order!). Note: given continuously evolving evidence about this topic, as more data are continuously collected/published, these advices may potentially need to be updated in the near future.

SIAARTI

This the algorithm for airways management in COVID-19 patients proposed by SIAARTI, Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (Italian Society of Anesthesia, Analgesia and Intensive Care)  available for download, along with other interesting documents on the SIAARTI website. This document include:
double check for indications for endotracheal intubation
team preparation
PPE donning/doffing
clinical checklist
airway instrumentation
tube position control and protective ventilation
transport.
Authors: M. Sorbello, I. Di Giacinto, F. Bressan, R. Cataldo, G. Cortese, C. Esposito, S. Falcetta, G. Merli , F. Petrini SIAARTI airways management study group.

Department of Anaesthesia and Intensive Care – The Chinese University of Hong Kong

Here an amazing graphics with principles of airway management in suspected or confirmed COVID-19 patients which may apply to Operative Room, Intensive Care Unit, Emergency Department and, eventually, ward; similar principles may be applied at extubation, by Albert Chan (@gaseousXchange on twitter) realized for the Department of Anaesthesia and Intensive Care – The Chinese University of Hong Kong, and proposed in lot of different languages (English, French, Spanish, Italian, German, Japanese, Portuguese, and simplified Chinese), with the purpose to try helping clinicians around the world; all versions are available for download here (high resolution) .

Criticalcarenorthampton & Propofology

The following represent a proposal of checklists when considering or performing airway intervention in suspected (& confirmed) COVID-19 patients, with pre-intubation, intubation and post-intubation approach , made by a collaborative group including (random order): Dr Jonny Wilkinson, Dr David Lyness, The ICS – Intensive Care Society, and the Midlands Coronavirus ITU Group. Proposed in different styles…
First one by Jonny Wilkinson (follow him on twitter @Wilkinsonjonny) available for download at Criticalcarenorthampton.com, with lot of COVID-19 resources including an intubation COVID trolley set up checklist.
The other two amazing ones by David Lyness: check COVID-19 dedicated page on his blog, Propofology blog (full resolution infographics & tons of other educational stuff related to SARS-CoV-2 infection), and follow him on twitter @Gas_Craic.

Intensive Blog

An update of the Alfred ICU guidelines for intubation of critically ills to include an appendix with specific considerations for SARS-CoV-2, outlining modifications for suspected COVID19 has been published by Julia Coull & Chris Nickson (follow them on twitter, @julia_coull & @precordialthump) check & download full document on Intensive Blog.

CanadiEM

In the last infographics, emerging best practices for performing tracheal intubation in this population, based on current evidence from China and prior understanding of SARS. Focus on what to do/avoid in this setting!
By Patrick Boreskie and published on CanadiEM website!


ECMO in COVID-19, message from the ELSO President

Video transcript

The Extracorporeal Life Support Organization, ELSO, is the global nonprofit organization for ExtraCorporeal Membrane Oxygenation (ECMO) and Extracorporeal Life Support (ECLS). We are working with our partners across the globe on the response to COVID-19 as it relates to the use of ECMO for supporting patients infected with the virus.
We are relying on the same sources as others for accurate information related to the rapidly evolving COVID-19 virus epidemiology. Specifically, we will continue to rely on the World Health Organization, the Centers for Disease Control, as well as, local health officials and governments as the situation evolves.  We remain a real-time authoritative resource because of ELSO’s global member centers which provide up-to-date information and data to allow our physicians and scientists to continually edit our recommendations.
COVID-19 can cause respiratory distress in some patients. ECMO has proven to be an effective option to support selective patients with severe respiratory distress, some of which are COVID-19 patients. We are tracking this information globally, including as part of our registry. 
In addition, we are launching new studies and data sharing agreements with our partners across the globe.  As an example, our Asia Pacific ELSO Chapter is coordinating efforts across the Asia Pacific region and globally to study ECMO in the treatment of patients with COVID-19.   The group’s trial, ExtraCorporeal Membrane Oxygenation for Coronavirus 19 Acute Respiratory Distress (ECMOCARD) will study the clinical data of COVID-19 patients where ECMO treatment was provided in more than 50 hospitals across 4 continents and 19 countries. This study has been endorsed by the World Health Organization and the international ECMO research group, ECMONet.
As new studies and results emerge, we will share relevant information on our website.  We will be updating this information with the urgency that this situation requires. We will have a link from our homepage: http://www.elso.org, social media sites on Twitter, Facebook, LinkedIn, and our ELSO ECMOed blog on COVID 19.
Twitter 
Facebook 
Linkedin
ELSO ECMOed blog
We are committed to coordinating with our ECLS centers across the globe and sharing updated information as this situation warrants. 
Thank you, and stay healthy.

Dr. Mark Ogino, ELSO President  

ELSO Webinar

ECMO in COVID-19

To date, there is limited worldwide experience with using ECMO in COVID-19 patients. The ELSO – Extracorporeal Life Support Organization continues to collect data through our member centers, and will provide recommendations as additional information becomes available. Moreover, to support the ECMO providers community, we are going to host a series of webinars to answer main questions related to Coronavirus outbreak and induced disease COVID-19 & the use of ECMO, involving leaders in the field of intensive care medicine and extracorporeal support ECLS. Any question, doubt or concern? Any particular topic you would like our expert to address?
Send all questions to webinar@elso.org or through DM & stay tuned, info on date/timing coming soon!

COVID-19 infographics

ECMO in COVID-19 related severe cardiopulmonary failure: visual summary of the recently published ELSO – Extracorporeal Life Support Organization Consensus guideline: unique considerations on when & how to provide ECLS in SARS-CoV-2 Coronavirus pandemic, with potential indications/contraindications. Download full document at https://bit.ly/ELSOCOVID19

Surviving Sepsis Campaign COVID-19 guidelines to support management of critically ill ICU patients with SARS-CoV-2 Coronavirus infection: here a graphic summary!
infection control, diagnosis & testing
hemodynamics support monitoring, fluids & vasoactives
non-invasive ventilatory support: SpO2 targets, conventional oxygen therapy, High Flow Nasal Cannula & Non-Invasive Positive Pressure Ventilation
invasive mechanical ventilation: MV settings, recruitment maneuver, prone posi
tioning, fluids, NMBAs & inhaled vasodilators
therapy: steroids antipyretics, antivirals, IVIg, convalescent plasma, rIFNs, chloroquine, tocilizumab & more!
full open access at https://bit.ly/SSCCOVID19

Basic advices & informal decisional algorithm by a study Group on management of critically ills COVID-19 patients based at Niguarda Ca’ Granda Hospital (Director Prof. R. Fumagalli) & Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Director Prof. A. Pesenti) in Milan,  Italy:
hot to set mechanical ventilation (initial acute phase, stabilization, weaning), hot to do recruitment maneuver & notes on porne positioning… to do or (maybe) not?
therapy: antivirals/adjuvants (be careful with lopinavir/ritonavir!) antibiotics, fluids/NE, analgesia & sedation, NMBA
temperature management
monitoring
Aim to stardardize treatments, optimizing outcome & resources consumption, and support physicians, nurses, HCPs dealing with severe respiratory failure related to COVID19, waiting for the response of the immune system, the most effective strategy!
By Thomas Langer & Nicola Bottino
Graphics by @foamecmo available both in English & Italian

Request full document with management advices to the authors
Thomas Langer thomas.langer@unimib.it
& Nicola Bottino bottino.nicola@gmail.com

PS Advices are based on preliminary informations collected during the first experience in China, and during the first week of the emergency in Lombardy, Northern of Italy; additional data ad evidence eventually arising will impose updating the recommendations.

COVID-19 network in Lombardy to early identify, triage & manage SARS-CoV-2 Coronavirus patients: JAMA livestream with Professor Maurizio Cecconi, Here a summary…
Do not underestimate! high percentage of patients will require hospitalization, high percentage will require intensive care: get ready, prepare now, work on protocols and have plans: outbreak could comes near to you! also check related paper by Prof Cecconi, Giacomo Grasselli and Antonio Pesenti just released on JAMA.

COVID19 dedicated GiViTI video conference with intensivists from North of Italy sharing their initial experience with Coronavirus SARSCoV19 epidemics: lung ultrasound LUS, prone positioning, MV, ECMO… it’s like a tsunami, you can’t understand if you are not in.
Recordings of the conference (for the ones speaking in Italian!) available link thanks to Istituto Mario Negri

How to manage critically ills with COVID19? be prepared! be familiar with case definition, ensure strict compliance with IPC, beware of diagnostic testing…
ESICM webinar with Prof Yaseen Arabi moderated by Lennie Derde. Here a graphics, slideset & summary available.

Missed the ESICM COVID-19 webinar with Professor Bin Du from China? here some dedicated notes: data about #Coronavirus pandemic, disease evolution, clinical features, organ failure & need for mechanical ventilation; check ESICM blog at for more data! full open access webinar here. A summary in the graphics.

ECMO infographics (& more)

Optimal site for providing extracorporeal cardio-pulmonary resuscitation ECPR in out-of-hospital cardiac arrest? maybe in the hospital, in the cath-lab better! here notes from the talk given by Jan Belohlavek, EuroELSO president, at EuroELSO2019 meeting: not ECLS alone, but a comprehensive approach including ECMO, with high quality bystander CPR/high quality ACLS, may have an impact on logistics for OHCA patients; we have technology but we still need to define proper patients & optimize logistics: randomized studies are absolutely necessary. Everything else is just an emotional bias. Visual abstract by @foamecmo
See you at EuroELSO2020 Congress, next May 6-8 2020 in London! register here

Perfect prime for ECMO circuit?? We take care for neonates, pediatrics, growing number of adult patients… there is no gold standard that defines ideal prime, as no prime is going to fit all these populations, and sometimes is a race against time!
here some notes freely based on the talk by Christine Franciscovich at 2019 ELSO Conference:
clear & blood priming, and factors to be considered when choosing
dilutional hematocrit calculation
additives options: calcium, albumin, heparin, NaHcO3…
lab/ABG on prime
graphics by Velia Marta Antonini @foamecmo

Prof. Bartlett on ECMOCARD

About the ExtraCorporeal Membrane Oxygenation for 2019 novel Coronavirus Acute Respiratory Disease ECMOCARD study, Professor Robert Bartlett, writes:”… our most important weapon in this crisis is data to predict and plan – on a global scale… a global problem needs global collaboration”. Here some words by Professor John Fraser, President of the Asia Pacific ELSO Chapter APELSO, introducing the study.
“Colleagues
As President of the Asia Pacific ELSO, I write to express my gratitude for all the work and collaboration from our brothers and sisters during this time of pandemic.
At times of global crisis, this is where teams show their strength. We have now more than. 50 centres in 20+ countries. over 4 continents that have signed up for the ECMOCARD study. Each night more centres are contacting us to join to work together; innovators and trailblazers that have come before us have given us the skills to hopefully be able to help the most critically unwell. It is in this environment that I am delighted that the father of #ECMO, Prof. Bob Bartlett has written to congratulate the ECMOCARD on the global collaboration we have created. Because a global crisis needs global collaboration for a global solution.
With Best wishes and thanks”
John
Attached, full text of Professor Bartlett letter.

ECMOCARD study

ExtraCorporeal Membrane Oxygenation for 2019 novel Coronavirus Acute Respiratory Disease ECMOCARD study is an multi-centre International study, conducted in all collaborating hospitals/ICU-based research networks in Asia, Australia & New Zealand (APELSO in collaboration with centres within the SPRINT-SARI and ISARIC Networks), and Europe, in COVID-19 patients requiringadmission to to ICU, Mechanical Ventilation &/or ECMO, to characterize:
incidence of ICU admission, need for non-invasive/invasive MV and ECMO 
risk factors, clinical features and severity of respiratory failure 
ECMO technical characteristics & duration of the run 
complications and ICU/Hospital survival 
requirements/time for approvals in participating network regions.

Aim is to recruit all eligible patients at each study location; patients will be studied specifically focusing on collecting data on MV, ECMO, main therapies (includinvasoactives, hypoxaemia rescue therapies, RRT), antibiotics/antivirals, adjunctive therapies, ie immunomodulators, corticosteroids, short-term outcomes.

Inclusion criteria

Laboratory-confirmed COVID-19 infection by real-time PCR and/or next-generation sequencing
Admission to an ICU

Exclusion criteria

MV for other concomitant causes 
ECMO for other concomitant causes 

Coronavirus

Family of RNA viruses which may infect mammals and birds, with 6 species known to cause human disease; 2 strains, the severe acute respiratory syndrome coronavirus SARS-CoV and Middle East respiratory syndrome coronavirus MERS-CoV have caused more serious, sometimes fatal, respiratory illnesses (reported mortality respectively 10% & 37%).

SARS-CoV-2 & COVID-19

In late December, 2019, in Wuhan, Hubei, China, new respiratory syndrome emerged with clinical signs resembling viral pneumonia and person-to-person transmission; analysis from lower respiratory tract samples corroborated emergence of novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 SARSCoV-2, causing  COrona VIrus Disease 2019 (COVID-19).

Update on COVID-19: from epidemiology to clinical characteristics, & some recommendations

Report of the World Health Organization (WHO)-China Joint Mission on Coronavirus Disease 2019:
– major findings about virus, outbreak, transmission dynamics, disease progression/severity, the China response and knowledge gaps;
– recommendations in five major areas to inform the ongoing response in China and globally, for countries with imported cases and/or outbreaks of COVID-19, for uninfected countries, for the public, and for the international community;
– main signs and symptoms, clinical case management and infection prevention and control. There are no specific antiviral or immune modulating agents proven (or recommended) to improve outcomes. All patients are monitored by regular pulse oximetry. The guidelines include supportive care by clinical category (mild, moderate, severe & critical), as well as the role of investigational treatments such as chloroquine phosphate, lopinavir/ritonavir, alpha interferon, ribavirin, arbidol. The application of intubation/invasive mechanical ventilation and ECMO in critically ills can improve survival; clearly, though ECLS is very resource consumptive, any health system would need to carefully weigh the benefits.
Full text open access at http://bit.ly/2uF3L7o

Clinical characteristics of COVID-19 disease in China, data regarding 1099 patients with laboratory-confirmed COrona VIrus Disease 2019 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in China on The New England Journal of Medicine: most of patients received diagnosis of pneumonia 91.1%; ARDS diagnosed in 3.4%, and shock in 1.1%; 5.0% of cases were admitted to the ICU, 2.3% underwent invasive mechanical ventilation, ECMO performed in 5 patients (0.5%) with severe disease, 1.4% died. On admission, the degree of severity categorized as nonsevere in 926 patients and severe in 173;.in patients with severe disease presence of any coexisting illness more common, and older age vs nonsevere cases (median of 7 years).
Systemic glucocorticoids given to 18.6% (44.5% if severe disease, 13.7% nonsevere). . Median duration of hospitalization 12 days.
Open access full text on NEJM.

Characteristics of & main lessons from COVID-19 Coronavirus outbreak in China: summary of a report of 72314 cases (data from Chinese CDC), with comparison of COVID-19 with SARS and MERS, and response to the novel Coronavirus epidemic.
Here some of the key findings:
age: 87%: 30-79 years, 1% respectively 10-19 & <10 years
spectrum of disease (confirmed cases): 81% mild, 14% severe, 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction or failure)
case-fatality rate (confirmed cases): 2.3%, 14.8% in patients aged ≥80 years, 49.0% in critical cases.
Next steps? As global society is more interconnected than ever, and emerging pathogens do not respect geopolitical boundaries, proactive investment in public health infrastructure & capacity crucial to effectively respond to epidemics; persisting in improving international surveillance, cooperation, coordination, & communication, is critical to be better prepared to respond to future new public health threats. Full text open access on JAMA.
Also check the epidemiological characteristics of outbreak COVID-19 on China CDC Weekly.