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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 7  |  Page : 49-55

Cardiopulmonary resuscitation in coronavirus disease 2019 patients


1 Department of Pediatrics, The Children's Hospital of San Antonio; Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas, USA
2 Department of Pediatrics, The Children's Hospital of San Antonio, San Antonio, Texas, USA
3 Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission22-Apr-2020
Date of Decision04-May-2020
Date of Acceptance14-May-2020
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Utpal Bhalala
The Children's Hospital of San Antonio, Baylor College of Medicine, 315 N. San Saba Street, Suite 1135, San Antonio 78207, Texas
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_69_20

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  Abstract 


We are faced with a novel human severe acute respiratory syndrome coronavirus-2 (CoV-2) that has been pronounced a pandemic by the World Health Organization in March 2020. This virus is highly contagious and can result in a disease that has been named CoV disease 2019 (COVID-19). It is characterized by severe pneumonia followed by a cytokine storm that can result in death. In such situations, performing cardiopulmonary resuscitation (CPR) can be a huge challenge because the virus can infect healthcare workers (HCW). For this reason, The American Heart Association and The Resuscitation Council (UK) have modified their guidance on performing CPR in COVID-19 patients to give them the best chance of survival while protecting the HCW. In this review, we aim to summarize the literature and share our experience in resuscitating COVID-19 patients or persons under investigations.

Keywords: Cardiac arrest, cardiopulmonary resuscitation, coronavirus disease 2019


How to cite this article:
Salameh M, Parikh P, Henderson C, Pierce M, Tolentino C, Bansal A, Bhalala U. Cardiopulmonary resuscitation in coronavirus disease 2019 patients. J Pediatr Crit Care 2020;7, Suppl S1:49-55

How to cite this URL:
Salameh M, Parikh P, Henderson C, Pierce M, Tolentino C, Bansal A, Bhalala U. Cardiopulmonary resuscitation in coronavirus disease 2019 patients. J Pediatr Crit Care [serial online] 2020 [cited 2020 Jul 14];7, Suppl S1:49-55. Available from: http://www.jpcc.org.in/text.asp?2020/7/7/49/285377




  Introduction/background Top


In December 2019, several cases of pneumonia due to an unknown organism were reported in Wuhan, Hubei Province, in China. A novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the cause of pneumonia by the Chinese Center for Disease Control (CCDC).[1] The World Health Organization named the syndrome: CoV disease 2019 (COVID-19). The virus has high transmissibility and infectivity, with R0 estimated to be between 2 and 3.[2] Up until the submission of this review, the confirmed cases are 2.4 million worldwide, with 166,000 deaths.[3] Because of its high infectivity, SARS-CoV-2 has been responsible for more deaths when compared to other CoVs such as SARS or Middle East respiratory syndrome.[4] Older patients with comorbidities seem to have higher mortality compared to younger patients.[5],[6] Due to the high mortality rate and the high infectivity of the disease, many concerns have been brought up regarding the safety of cardiopulmonary resuscitation (CPR) when performed on COVID-19 patients or persons under investigations (PUIs). In this review, we will discuss the current literature and recommendations of CPR in neonates, children, and adults with suspected or proven SARS-CoV-2 infection.

General considerations

Due to the high infectivity of the COVID-19 patients, The American Heart Association (AHA) and The Resuscitation Council in the UK developed interim guidance for the resuscitation of COVID-19 patients.[7],[8] Those guidelines clearly focused on the safety of healthcare workers (HCW). While we are continuously learning the pathophysiology of COVID-19, the AHA interim guidance modified the recommendations of basic life support, advanced cardiovascular life support and pediatric advanced life support algorithms to accommodate for those pathophysiologic differences compared to commonly encountered cases of cardiac arrest in adults.[7] Because hypoxia is the leading cause of cardiac arrest in COVID-19 patients, oxygenation and ventilation strategies with lower aerosolization risk should be prioritized. Those recommendations include:

  • Use a bag-mask [Figure 1]a or T-piece resuscitator in neonates [Figure 1]b with a high-efficiency particulate air (HEPA) filter and a tight seal before intubation
  • Early intubation and connection to a closed-circuit mechanical ventilator that includes HEPA filter, in-line suction catheter and end tidal carbon dioxide (ETCO2) monitor line
  • The most experienced intubator should be given the lead to increase the chances of successful first-pass intubation
  • Chest compressions should be paused while intubating the patient
  • Video laryngoscopy should be considered, if available, as it decreases the exposure to the patient's secretions
  • In adults, minimize the duration of bag-mask ventilation. Passive oxygenation with nonrebreather face mask whenever possible
  • Manual ventilation should be performed with a HEPA filter [Figure 1]a
  • Consider supraglottic airway with HEPA filter if intubation is delayed
  • Consider postintubation sequence to minimize aerosolization:
  • Figure 1: Bag-mask. (a) and T-piece resuscitator in neonates. (b) With a high-efficiency particulate air (filter and a tight seal before intubation. Manual ventilation performed with a high-efficiency particulate air filter [Figure 1a]

    Click here to view


    1. Inflate endotracheal tube (ETT) cuff immediately
    2. Clamp endotracheal tube following removal of the stylet
    3. Attach ventilator to the patient (Include HEPA filter, ETCO2 line, inline suction catheter)
    4. Unclamp
    5. Start mechanical ventilation.


  • Minimize disconnections of the closed circuit.


In hospital cardiac arrest

The transmission of SARS-CoV-2 continues to be under investigation; however, new evidence points toward multiple ways of transmission, including aerosol, gastrointestinal secretions, tears, and conjunctival secretions.[9],[10],[11],[12] For those reasons, certain recommendations should be followed to protect HCW while performing CPR on patients who are infected or suspected to have COVID-19. Those recommendations can be broadly looked at from three different angles:

  1. Personal protective equipment (PPE): It is of utmost importance to don PPE before entering the room. The Resuscitation Council in the UK published a statement in early April and clearly stated that, “In situations where there isn't “gold standard” PPE prior to starting CPR, a senior clinician, who can decide the level of protection that must be deployed, must perform a risk assessment”.[8] The AHA also focused on the importance of donning PPE before entering the scene to perform CPR[7]
  2. “Social distancing to mitigate the spread of the disease:” While this is an impossible undertaking while resuscitating a patient, a few recommendations were made to decrease the possibility of HCW contracting the virus. First, the number of personnel in the scene should be limited.[7],[8] Second, the use of a negative pressure room with anteroom could help with minimizing the contact between the patient and the other HCW.[7],[8] In those situations, a nurse will stay in the anteroom and make sure that no one other than the assigned team members will be inside the room. Our team has developed a model, in which there is a certain number of personnel with specific assignments in the room [Figure 2]. All other members will stay outside the room, including the nurse who draws up medications from crash/code cart and circulating nurse. Communication can be achieved through whiteboard on either side. The use of electronic equipment and plastic containing electronic devices should be avoided, as the virus could sustain viability on plastic surfaces for days.[9] However, this can be very difficult sometimes, especially if the rooms are not equipped with glass doors. In those situations, different modalities were suggested and include baby monitors, radio systems, and finally, a pair of wireless earphones that are connected to a phone that is placed outside the room
  3. Controlling the situation: A huddle should be performed before each shift with assigning roles for team members. Mock codes can be of high importance to set expectations and help with detecting flaws. High priority should be given to individualized discussions regarding the futility and appropriateness of resuscitation efforts.[7],[8] Advanced directives need to be signed and clearly communicated to all team members to protect HCW.[8] The risk factors of survival should be considered when adopting such policies.[7]


This is a model that our team has developed and is adopting for all COVID-19 patients or PUIs.
Figure 2: Schematic room diagram of cardiopulmonary resuscitation in coronavirus disease 2019 patient or persons under investigations. (a) Represents ideal scenario in which coronavirus disease 2019 patient or persons under investigation is in negative pressure room and there is a nurse in anteroom who acts as personal protective equipment and door police to maintain personal protective equipment precautions; (b) Represents scenario in resource-limited setting in which coronavirus disease 2019 patient or persons under investigation is being resuscitated by a limited number of medical team members in an open space with screens around the patient to minimize viral spread

Click here to view


  • In anticipation of possible codes, conduct a huddle at the beginning of each shift and identify specific team members as resuscitation/airway management team. This team will respond to the airway and resuscitation needs of the patient infected with COVID-19 or PUIs. The team will include:


    • One medical doctor or nurse practitioner-Code team leader
    • Four registered nurses (RNs)-two for alternating chest compressions and medication supply (resource handler 1), one for medication administration, and one for documentation (code co-leader)
    • Two respiratory therapists (RTs)-for airway management and setting up the mechanical ventilator.


  • When a patient with COVID-19 deteriorates in an intensive care unit (ICU), the COVID-19 code team will be available for consultation and escalation of care.
  • Anyone who is likely to enter the patient's room must always use appropriate isolation precautions.
  • Crash/Code cart and airway cart should stay outside the patient's room. When indicated, a defibrillator can be brought inside the room.
  • The RNs and pharmacists who are drawing up medications from the code/crash cart and RNs and RTs pulling out airway resources from the airway cart to coordinate medications and supplies through the resource handler in the anteroom.
  • During CPR, preferably leave the patient on the ventilator (with HEPA filter between ETT and ventilator).[7] Considering the following:


    • Adjust the ventilator mode to pressure control/assist control
    • Target appropriate chest rise or tidal volume of 6 mL/kg of ideal body weight (pediatric/adult) or 4–6 mL/kg (Neonates)
    • Adjust FiO2 to 1.0
    • Utilize low Positive End-Expiratory Pressure (to improve the preload)
    • Adjust respiratory rate to an appropriate age population (10 breaths/min for pediatric/adult or 30 breaths/min for neonates)
    • Minimize the trigger/sensitivity (to prevent autocycling with compressions, preventing excessive ventilation and potential air trapping)
    • Minimize alarm settings to prevent alarm fatigue
    • If manual ventilation used, ensure HEPA filter is placed on the airway appliance
    • Cover the patient in plastic and perform CPR.


  • Documenter will document on a regular code sheet and when the event is over, the documenter will attach the sheet to a glass door from within the patient's room. A nurse outside will copy all the details and get it signed by the code team members. Subsequently, the original code sheet created within the patient's room to be discarded appropriately based on the PPE protocol.
  • Consider using mechanical CPR devices for adults and adolescents who meet height and weight criteria.[7]


Out of hospital cardiac arrest

Multiple studies have shown improved survival when out of hospital cardiac arrest (OHCA) occurs if early bystander CPR was initiated.[13],[14],[15] Due to their supposed exposure to the virus, a lay rescuer, if willing and capable, should “at least” start hands-on CPR with chest compressions and cover the mouth and nose of the patient to decrease transmission.[7] In children with COVID-19 who develop OHCA, the recommendation is that the lay rescuer should start CPR with chest compressions and consider mouth-to-mouth breathing using a cloth or mask to decrease the risk of transmission of the virus.[7] The AHA guidance recommends using an automated external defibrillator, when available, to assess and treat victims of OHCA.[7] Telecommunicators should screen all patients for COVID-19 risks while providing guidance on how to perform CPR. EMS should be alerted and instructed on donning proper PPE if there is any suspicion of COVID-19 infection.[7] While this might be a very difficult undertaking, families and other contacts with suspected patients should not be transported. Avoiding transporting the patient to the hospital should be considered if they do not have return of spontaneous circulation after appropriate efforts of CPR.[15]

Special considerations

Prone cardiopulmonary resuscitation

The efficacy of performing chest compressions in the prone position is not known yet.[16] However, unless able to do so without risking the disconnection of equipment and aerosolization, turning the patient to the supine position to perform chest compressions should be avoided in patients with an advanced airway.[7] The practitioner should perform chest compressions with the patient in the prone position with hands in the standard position over the T7/10 vertebral bodies while placing the defibrillator pads in the anterior-posterior position.[7]

Extracorporeal cardiopulmonary resuscitation

Extracorporeal CPR (E-CPR) should be avoided in adults due to the high mortality rate and the severe shortage of medical supplies, personnel and PPE.[17] However, given that the disease is less severe in pediatric patients[18] and survival has been shown to improve when using E-CPR,[19] those recommendations can change according to the ability of the center to provide extracorporeal membrane oxygenation in such settings. When the decision is made to initiate E-CPR, the surgeons and the operating room (OR) team members should be alerted of the diagnosis or suspicion of COVID-19.

Recommendations for the management of neonates born to mothers with severe acute respiratory syndrome coronavirus 2 infection

As per the Center for Disease Control and Prevention (CDC), it is not known if pregnant patients are at increased risk of acquiring SARS-CoV-2 infection or whether they are at greater risk of developing the serious illness as a result. Disruption of the placental barrier from maternal-fetal hemorrhage may potentially transmit the virus and or antibodies to fetal circulation. Based on the evidence of other severe respiratory illness suggest that newborns, especially preterm infants, are at increased risk of postnatal infection.[20]

In a study by Chen et al., nine infants born to SARS-CoV-2 infected mothers had normal Apgar scores.[21] In another study, there was no difference in fetal distress, meconium-stained amniotic fluid, preterm birth, and neonatal asphyxia between pregnant mothers with SARS-CoV-2 compared to those who do not have the infection.[22]

Very little data are available regarding outcomes due to postnatal infection. A retrospective analysis by Zhu et al. included ten neonates born to nine SARS-CoV-2 positive mothers. There were four full-term and six premature neonates. Two of them had fevers, six developed respiratory distress syndrome, and two had thrombocytopenia with abnormal liver enzymes. Five infants were discharged home, and when the article was published, four continued to be hospitalized in a stable condition, while one child died. All infants were negative for SARS-CoV-2 test; thus, the complications most likely were due to prematurity and not SARS-CoV-2 infection.[23] Two other reports have detected SARS-CoV-2 in 4 out of 34 tested newborns. Those infants presented with respiratory distress. Pneumonia was clinically and radiologically diagnosed, and there was variability in neonatal inflammatory and transaminase levels in those neonates.[24],[25]

Guidelines for perinatal care provided by the CDC and by the American College of Obstetricians and Gynecologists (ACOG) support that neonates born to women with SARS-CoV-2 as well as neonates born to women with testing for SARS-CoV-2 pending at the time of delivery should be considered as PUIs.[26],[27]

Delivery room management

Delivery room management is very involved, well-coordinated management, which involves many specialties, including obstetrics, neonatology, anesthesia, and other disciplines. The coordination involves discussion of the team members before and during delivery, place and mode of delivery, PPE and postdelivery management. This management can vary as per center-specific policies, which are influenced by ACOG, CDC, and American Academy of Pediatrics (AAP) guidelines.[26],[27],[28] Simulation regarding the procedure and policies at each center can help identify problem areas in the protocol that can be rectified before taking care of PUIs or SARS-CoV-2 infected patients.

Mode and location of delivery

As per maternal and fetal indications, the obstetric and anesthesia team should decide which mode of delivery and anesthesia the patient will undergo. Delivery of a suspected or confirmed SARS-CoV-2 patient should preferably take place in a center with the capacity to care for critically ill adults and neonates and have negative pressure rooms to isolate those patients. Other guidelines include:

  • There should be predesignated labor rooms and ORs and established protocols for triaging patients to designated areas
  • The designated delivery/OR should have adequate equipment including a radiant warmer, airway accessories, and neonatal cart with medications/fluids/lines for advanced resuscitation as recommended by the AAP and neonatal resuscitation program (NRP)
  • Cesarean deliveries in the OR may result in significant exposure of HCW to the virus compared to spontaneous delivery. Therefore, in a situation where there is an increased risk, proper PPE should be used
  • The OR should be closed, and the personnel should stay inside the room until 2–3 air filtration cycles occur, which could range from 10 to 30 min.


Neonatal resuscitation

During resuscitation of a neonate, the current AAP and NRP recommendations should be followed.[28] We recommend the following:

Personal

  • To reduce the burden of exposure, it is recommended to have a designated neonatal resuscitation team for newborn children delivering to a PUI or SARS-CoV-2 positive mothers[28]
  • A minimum number of neonatal personnel should be in the room [Figure 3]
  • The individual most experienced in neonatal intubation should intubate the infant to reduce the number of attempts, which would reduce the risk of aerosolization.
Figure 3: Schematic room diagram of delivery room resuscitation in a neonate born to a coronavirus disease 2019 mother or persons under investigation

Click here to view


Location of neonatal resuscitation

  • The optimal location for neonatal resuscitation is adjacent to a negative pressure room
  • If this is not possible, resuscitation should take place in the same room with at least 6 feet (2 m) distance with a physical barrier between the mother and the newborn
  • We recommend conducting resuscitation in an isolette
  • Regardless of the gestational age, the newborn should be transported in a closed isolette and maintained in there for postresuscitation care.


Airway management

  • A newborn airway should be managed as per NRP recommendations
  • Those who are involved in airway management should don proper PPE
  • To reduce aerosol from continuous positive airway pressure or positive pressure ventilation via facemask and closed ventilator circuits with appropriate HEPA or bacterial/viral filters should be used
  • Laryngeal mask airway reduces aerosol generation and could be an alternative to face mask ventilation[29]
  • Surfactant administration and open suctioning of the endotracheal tube could generate aerosols, and wearing appropriate PPE should mitigate exposure.


Advanced resuscitation

There is evidence that SARS-CoV-2 infection leads to premature birth.[21],[22],[23] However, there is not enough evidence to support that it increases the morbidity and mortality of infants. Therefore, no extra precautions need to be taken in neonatal resuscitation.

Post stabilization

The neonate should be transported in a closed isolette and transferred to a negative pressure room. The disposition of the neonate to Neonatal ICU or newborn nursery should be based on institutional policies.


  Conclusion Top


Performing CPR on COVID-19 patients or PUIs can lead to SARS-CoV-2 infection in HCW. Caution must be taken to reduce the risk of infection and to mitigate the spread of the disease. We recommend isolating those patients in a negative pressure room while wearing proper PPE, having a limited number of personnel in the room, and having a controlled situation while performing CPR. While it is a rare encounter, resuscitation of a neonate to a SARS-CoV-2 infected mother should follow the same recommendations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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