American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Clinical Issues and Guidance

ACS Issues Statement on the Importance of Maintaining the Emergency Care System during the COVID-19 Pandemic

As many U.S. cities are challenged with rapidly rising numbers of COVID-19 cases, their health care systems are at risk of being overwhelmed. This puts lives at risk, not only for patients suffering from COVID-19 infection, but patients with common time-sensitive medical and surgical emergencies such as traumatic injury, myocardial infarction, and stroke. In light of the challenges currently faced by the surge of COVID-19 patients in New York City and likely to follow in many other US cities, we call for strategies to preserve capacity and capability to care for these patients. The ACS has outlined below a series of recommendations for hospital and health care system leaders to consider when facing this challenge.

Briefly, the statement offers the following recommendations:

  1. Engage the physician leadership of the trauma, cardiac, and stroke systems in the regional planning and response processes
  2. Review trauma registry and hospital admission data to understand the usual volumes of patients with time-sensitive emergencies seen in the hospital/health care system and what proportion will need mechanical ventilation and intensive care unit (ICU) admission.
  3. Identify the leading trauma centers and specialized stroke and STEMI centers in the region and develop a strategy to preserve a resuscitation area in the emergency department (ED) and ICU and operative resources to care for these patients during the COVID-19 surge.
  4. Many trauma surgeons also are surgical intensivists. If trauma surgeons are needed to care for COVID-19 patients, identify other surgical specialists who can be available to staff trauma resuscitation and emergent operations.
  5. Develop a regional medical operations center to coordinate the distribution of COVID-19 patients across the area hospitals.
  6. If a cardiac/stroke/trauma center is reaching capacity and can no longer care for critical patients, then a strategy should be developed to support transport of patients (including COVID-19-positive patients) out of that facility to restore capacity or divert those patients to a facility capable of providing the same level of emergency care, assuming one is available within a reasonable distance.
  7. If a regional health care system is overwhelmed and in crisis, then the regional medical operations center should consider equitable distribution of patients to other regions. This should be carefully coordinated to restore adequate standards of care in the region in crisis, while not negatively impacting the receiving regions’ ability to provide safe care.

Promising Therapeutics

The use of hydroxychloroquine (HCQ) and azithromycin for COVID-19 disease continues to be a hotly debated issue. It is being used widely, but the data supporting efficacy and safety is very limited. It has been advocated in small studies and discouraged in others. A recent French study from Paris shows no increase in viral clearance in COVID-19 patients and no improvement in clinical outcome in a limited series of 11 patients treated with both HCQ and azithromycin. This outcome is in contrast to another recent French study from Marseille that showed rapid clearance of SARS-CoV-2 with the same drug regimen.

In this edition, we provide an update on promising therapeutic options. To that end, an article in the April 6 issue of the Wall Street Journal notes that more than 140 experimental drug treatment and vaccines for the coronavirus are in development worldwide. Most of these therapeutics are in the early stages of testing, with 11 already in clinical trials. In all, including drugs approved for other diseases, 254 clinical trials are testing treatments or vaccines for the virus—many spearheaded by universities and government research agencies.

Michigan Collaborative Provides Extensive Best Practices for COVID-19 and Critical Care Patients

As the case volume of COVID-19 patients continues to surge in the U.S. and globally, surgeons and other professionals are seeking easy-to-access information on how to provide quality care to these individuals. The Michigan Critical Care Collaborative Network (MCCCN)—a statewide collaboration of health care professionals managing COVID-19 patients—has developed a repository of best practices gleaned from lessons learned around the world. These resources include information on frontline provider treatment tips, intensive care unit (ICU) medications, airway and respiratory therapy, emergency general surgery and operating room management of COVID-19 patients and persons under investigation, and guidance for personal protection equipment for wards, ICUs, and the trauma bay.

Role of Prone Positioning in Management of COVID-19-Related ARDS

Randomized prospective trials and observational studies involving patients with Adult Respiratory Distress Syndrome (ARDS) have shown improved outcomes with the use of prone positioning. Information and resources that may be useful for surgeons called upon to care for patients with COVID-19-related ARDS can be accessed here.

A useful review of available data appeared in an article by Scholten and coauthors  in Chest, 2017;1 a link to the full-text article is provided here. The article contains a useful discussion of beneficial physiologic changes that occur when patients with ARDS are placed in the prone position. The weight of the heart and abdominal viscera on the dorsal segments of the lung is reduced and this permits improvements in distribution of inspired gases. This redistribution also prevents alveolar de-recruitment and improves results of maneuvers for alveolar recruitment. Concomitant changes in cardiac function result in more uniform distribution of pulmonary blood flow.2 The overall result is improved oxygenation, increases in lung compliance, and more uniform distribution of ventilation.

The authors noted that the optimum duration of prone positioning is unclear; they recommended patient proning be continued for 16 hours/day until pulmonary variables were consistently improved, and that improvement was maintained when the supine positioning was resumed (see summary table referenced below). Other approaches to the duration of prone positioning may be appropriate in patients that require, for example, wound care, management of an open abdomen, etc. In these settings, shorter periods (e.g., six hours) repeated during the day are effective. Some challenges that arise during the use of prone positioning include increased secretion production due to recruitment of fluid-filled alveoli. Protocols for management of analgesia/sedation will be needed when prone positioning is used. A comprehensive source offering advice to health care professionals who are managing critically ill patients with COVID-19 infection has been produced by the Michigan Critical Care Collaborative.

Summary Recommendations for Prone Ventilation

The authors cited data from one large prospective trial showing that prone positioning not only improves oxygenation, but also lowers mortality in patients with moderate-severe ARDS. Other data cited in the review documented adverse effects of prone positioning in obese patients; in this patient group, prone positioning increased intra-abdominal pressure. The authors suggested that abdominal pressure monitoring may be useful along with measures to monitor gastric residual volumes. The authors emphasized the need for caution when considering use of prone positioning in obese patients with ARDS. If prone positioning is used, placing the obese patient in reverse Trendelenburg position has been shown to facilitate monitoring, gastric emptying, and management of abdominal hypertension.

A summary table that lists the indications for prone positioning, recommendations for safe positioning, and criteria for stopping the intervention is available below.

Major Trials of Prone Ventilation in ARDS

Prone positioning may also be useful for reducing the risk of progression to endotracheal intubation and ventilator support in patients with ARDS. A study by Ding and coauthors3 showed that combining prone positioning with high flow nasal cannula oxygen delivery or other forms of noninvasive ventilation reduced the risk of intubation and ventilator management in patients with moderate-severe ARDS.

The fact that placing patients with ARDS in the prone position requires careful protection of the airway and necessitates use of several staff members may be a daunting prospect in times of staff shortages because of the increased patient loads associated with the COVID-19 pandemic. Data are available, however, showing that implementation of a prone positioning protocol is cost effective and associated with significant patient benefit.4

A useful review of prone positioning that includes a video depicting a safe method for proper positioning of a patient is available on Twitter and can be accessed using this link.

References

  1. Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of ARDS With Prone Positioning. Chest. 2017;151(1):215-224.
  2. Saran S, Gurjar M, Azim A, et al. Trans-Esophageal Doppler Assessment of Acute Hemodynamic Changes Due to Prone Positioning in Acute Respiratory Distress Syndrome Patients. Shock. 2019;52(4):e39-e44.
  3. Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24(1):28.
  4. Baston CM, Coe NB, Guerin C, Mancebo J, Halpern S. The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome. Crit Care Med. 2019;47(3):e198-e205.

Management of Symptomatic Gallbladder Disease and Acute Cholecystitis during the COVID-19 Pandemic

Click here to read guidance on management of symptomatic gallbladder disease during the COVID-19 pandemic is to ensure that surgeons can accomplish the following:

  • Provide the best surgical care possible for non-COVID-19 patients with gallbladder disease.
  • Limit exposure of all patients to the coronavirus.
  • Limit exposure of health care workers to the coronavirus.
  • Preserve resources to care for coronavirus patients.

COVID-19 Treatment Updates from the Front Lines in New Orleans

David Janz, MD, a critical care medicine specialist at University Medical Center New Orleans (UMCNO), LA, outlines the treatment protocol UMCNO is using to treat critical COVID-19 patients. The video addresses treatment of COVID-19 for respiratory distress. Watch the 45-minute video.

JACS Article Describes Tiered Surgical Response Plan for COVID-19

The acute care division at Atrium Health’s Carolinas Medical Center, Charlotte, NC, has developed a tiered plan for marshaling limited resources during the COVID-19 pandemic. The article posted in the Journal of the American College of Surgeons (JACS)—"Maximizing the calm before the storm: A tiered surgical response plan for COVID-19”—focuses on acute care surgeon deployment, recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.

National Academies of Sciences, Engineering, and Medicine Provides Standards of Care Guidance

To support crisis standards of care (CSC) decision making at all levels, the National Academies of Sciences, Engineering, and Medicine (NASEM) has released a rapid expert consultation document outlining core principles of CSC planning and implementation. Developed by NASEM’s Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, this document was based on the previous decade of National Academies reports and underscores a primary principle of CSC—achieving the best outcomes for a group of patients rather than focusing on an individual patient.
The key elements of CSC planning include ethical grounding; engagement, education, and communication; legal considerations; indicators, triggers, and responsibilities; and evidence-based clinical operations. The NASEM document includes an appendix with examples of shortages that can trigger CSC.

Implementing CSC planning is facilitated, in part, by COVID-19 emergency declaration blanket waivers released by the Centers for Medicare & Medicaid (CMS). The waivers, retroactive to March 1, allow hospitals to establish additional treatment locations, expand access to telehealth, permit additional workforce capacity, and eliminate some administrative requirements.

University of Nebraska Medical Center Releases New Perioperative Procedure Maps

The University of Nebraska Medical Center (UNMC) April 3 released recent updates to its guidelines for decision making in the perioperative management of patients who require anesthesia and surgical services. These guidelines were developed with the evolving prevalence of COVID-19 in mind and in the context of responsible use and availability of personal protective equipment.

Deployment of Surgeons for Out-of-Specialty Patient Care

The COVID-19 pandemic has inflicted unprecedented stresses upon health care institutions and the caregivers who provide the frontline services needed to maximize the chances of survival and return to normalcy for patients who are infected and develop clinical symptoms. In this challenging time, it will be necessary to deploy surgeons to work outside of their usual specialty to maximize the effectiveness of available clinicians.

Early resources that will be valuable at the time of entry into the intensive care unit care activities include these Society of Critical Care teaching modules for noncritical care clinicians and disaster response recommendations.