Airway Management in COVID-19 - University of Manitoba · Airway Management in COVID-19: It’s more than just about aerosols Hilary P. Grocott, MD, FRCPC Professor, Departments of

Canadian Journal of Anesthesia Journal canadien d‘anesthésie springer.com/12630

COVID-19

Airway Management in COVID-19: It’s more than just about aerosols

Hilary P. Grocott, MD, FRCPC

Professor, Departments of Anesthesia, Perioperative & Pain Medicine and Surgery University of Manitoba

Editor-in-Chief Canadian Journal of Anesthesia

@DrGrocott @CJA_Journal


Airway Management in COVID-19: It’s also about hemodynamics





COVID-19


Airway Management in COVID-19: It’s also about hemodynamics





COVID-19

TEXT QUESTIONS: 204-291-8377


• Stipend from the Canadian Anesthesiologists’ Society

Disclosures



• Not prescriptive • Information evolving • Be comfortable with uncertainty • Be adaptable with change

Disclosures


• Not prescriptive • Information evolving • Be comfortable with uncertainty • Be adaptable to change

Disclosures


April 7, 2020

December 1, 2019

Weekly Publications: “COVID-19” or “coronavirus” or “SARS-CoV-2”

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Flattening of the curve


April 7, 2020

December 1, 2019


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First anesthesia or critical care publication


Can J Anesth doi: 10.1007/s12630-020-01591-x

77K downloads 43 citations


Wax RS, Christian MD. Can J Anesth doi: 10.1007/s12630-020-01591-x


The COVID-19 Infodemic

Total annual downloads: 1.3M


The COVID-19 Infodemic

Total annual downloads: 1.3M 17 COVID-related articles

Downloads past 7 weeks: 290K


Cook TM et al. Anaesthesia 2020 doi:10.111/anae.15054


Airway Management Algorithm


Managing the Airway in Acutely-ill COVID-19 patients


Airway PoCUS

Kong E Y-T et al. Can J Anesth 2018;65:473-484


Airway PoCUS: cricothyroid membrane




thyroid cartilage




thyroid cartilage cricoid cartilage





CTM






CTM

Mark it prior to anesthesia induction in the “uncertain airway”


Front Of Neck Access



Induce Anesthesia



Induce Anesthesia “Rapid Sequence Induction”



Induce Anesthesia



Optimize the cardiovascular system

Induce Anesthesia


COVID-19: myocardial effects

N = 416 hospitalized COVID-19 patients

Shi S et al. JAMA Cardiol doi: 10.1001/jamacardio.2020.0950



N = 416 hospitalized COVID-19 patients N = 82 (19.7%) with cardiac injury

hs-Troponin-I > 99ile



N = 82 (19.7%)

N = 332 (80.2%)



Surv

ival

(%)


COVID-19: myocardial injury pathophysiology

Libby P. JACC: Basic to Translational Science (2020) doi:10.1016/j.jacbts.2020.04.001

Increased Oxygen Demand Decreased Oxygen Supply




Decreased Oxygen Supply Increased Oxygen Demand




Direct Myocardial Infection

Secondary Myocardial Involvement

Type-2 myocardial infarction

Most cases mixed?

Fulminant viral myocarditis


Hemodynamic Considerations of Intubation

• “Acutely-ill” COVID-19 patient • Myocardial dysfunction



• “Acutely-ill” COVID-19 patient • Myocardial dysfunction • ARDS (acute respiratory distress syndrome)


Gattinoni L et al. Intensive Care Med doi: 10.1007/s00134-020-06033-2

COVID-19: “new” concepts in ARDS


COVID-19: new concepts in ARDS


L-phenotype

• Low elastance • Low lung weight and recruitability • V/Q mismatch • Loss of hypoxic vasoconstriction • Hypoxemia-hypocapnia • “Absence” of dyspnea • Pulmonary artery pressures normal



L-phenotype

H-phenotype



• High elastance • High lung weight and recruitability • Shunt • Hypoxemia-hypercapnia • Pulmonary hypertension


Progression of infection Patient self-inflicted lung injury (P-SILI)

L-phenotype

H-phenotype



• High elastance • High lung weight and recruitability • Shunt • Hypoxemia-hypercapnia • Pulmonary hypertension



• “Acutely-ill” COVID-19 patient • Myocardial dysfunction • ARDS • Pulmonary hypertension • RV dysfunction


Right Ventricular Dysfunction

LV RV

Normal RV


Right Ventricular Dysfunction

LV RV LV RV

Normal RV RV Dysfunction


Managing RV failure and Pulmonary Hypertension

Hrymak C et al. Can J Cardiology 2017;33:61-71


Transeptal gradient (TSG) & Ventricular interdependence

modifed from Hrymak C et al. Can J Cardiology 2017;33:61-71

Normal: TSG = 100 mmHg Elevated PA pressures: TSG = 20 mmHg



• TSG maintains normal RV architecture/scaffold • 20-40% of RV function depends on normal LV function • Hypotension decreases TSG • Optimize PVR





• TSG maintains normal RV architecture/scaffold • 20-40% of RV function depends on normal LV function • Hypotension decreases TSG • Increase in PVR decreases TSG




Right Ventricular Blood Flow/Ischemia



Importance of systolic & diastolic pressure (MAP)





Hypotension RV Ischemia

Importance of systolic & diastolic pressure (MAP)




2 9

5

Card

iac

Out

put

Hemodynamic Goals for RV failure: fluid loading?

Failing RV

Normal RV



2 9

5

Card

iac

Out

put

Hemodynamic Goals for RV failure: fluid loading?

Failing RV

Normal RV

Don’t over-fill!


• Optimize fluid loading (Ringer’s Lactate 250 mL) • Avoid hypotension - vasopressors • Reduce PVR

- no acute role for pulmonary vasodilators (systemic hypotension effects)

• Inotropic support

Hemodynamic Management of the Airway in Acutely-ill COVID-19 patients


Vasopressor and Inotropic Support for RV failure

Drug Inotropy SVR PVR Phenylephrine Norepinephrine Vasopressin Dobutamine Epinephrine Milrinone



• Optimize fluid loading (Ringer’s Lactate 250 mL) • Avoid hypotension - vasopressors • Avoid increases in PVR



• Optimize fluid loading (Ringer’s Lactate 250 mL) • Avoid hypotension - vasopressors • Avoid increases in PVR


• Inotropic support



Drug Inotropy SVR PVR Phenylephrine Norepinephrine Vasopressin Dobutamine Epinephrine Milrinone

Vasopressor and Inotropic Support for RV failure



“Rapid Sequence Induction”

SUMMARY


Induce Anesthesia




Induce Anesthesia



- rocuronium 1.5 mg/kg - ketamine + midazolam/propofol/fentanyl - Phenylephrine bolus syringe - Infusions: Norepinephrine + Epinephrine or Dobutamine


Induce Anesthesia



- rocuronium 1.5 mg/kg - ketamine + midazolam/propofol/fentanyl - Phenylephrine bolus syringe - Infusions: Norepinephrine + Epinephrine (or Dobutamine)


@CJA_Journal @DrGrocott


[email protected]

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Airway Management in COVID-19 - University of Manitoba · Airway Management in COVID-19: It’s more than just about aerosols Hilary P. Grocott, MD, FRCPC Professor, Departments of