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SARS Update: Focus on Airway Management

SARS Update: Focus on Airway Management. Robert C. Jones, M.D. LtCol, USAF, Medical Corps Staff Anesthesiologist Andrews Air Force Base, Maryland E-mail: rob@notbob.com Web site: http://www.notbob.com. Overview. A Brief History of the 2003 SARS epidemic The SARS Virus Diagnosis

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SARS Update: Focus on Airway Management

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  1. SARS Update: Focus on Airway Management Robert C. Jones, M.D. LtCol, USAF, Medical Corps Staff Anesthesiologist Andrews Air Force Base, Maryland E-mail: rob@notbob.com Web site: http://www.notbob.com

  2. Overview • A Brief History of the 2003 SARS epidemic • The SARS Virus • Diagnosis • Treatment • Lessons Learned from China/Canada • Airway Management Guidelines • Discussion Issues

  3. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir

  4. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir • Nov 02: Index case in Guangdong Province, PRC; most early cases among food handlers (civets, raccoons…)

  5. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir • Nov 02: Index case in Guangdong Province, PRC; most early cases among food handlers (civets, raccoons…) • Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou (Superspreader) massive outbreak Hotel Metropole, Kowloon, HK, PRC

  6. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir • Nov 02: Index case in Guangdong Province, PRC; most early cases among food handlers (civets, raccoons…) • Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou (Superspreader) massive outbreak • Mar 03: Amoy Gardens outbreak  high prevalence of diarrheal disease due to poor sanitation design

  7. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir • Nov 02: Index case in Guangdong Province, PRC; most early cases among food handlers (civets, raccoons…) • Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou (Superspreader) massive outbreak • Mar 03: Amoy Gardens outbreak  high prevalence of diarrheal disease due to poor sanitation design • Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S.

  8. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir • Nov 02: Index case in Guangdong Province, PRC; most early cases among food handlers (civets, raccoons…) • Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou (Superspreader) massive outbreak • Mar 03: Amoy Gardens outbreak  high prevalence of diarrheal disease due to poor sanitation design • Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S. • Apr 03: Virus identified, sequenced in record time

  9. Brief History of SARS • ? Zoonotic spread from unknown animal reservoir • Nov 02: Index case in Guangdong Province, PRC; most early cases among food handlers (civets, raccoons…) • Feb 03: Hotel Metropole, HK, PRC Physician from Guangzhou (Superspreader) massive outbreak • Mar 03: Amoy Gardens outbreak  high prevalence of diarrheal disease due to poor sanitation design • Mar 03: SARS spreads to Beijing, Taiwan, Toronto, U.S. • Apr 03: Virus identified, sequenced in record time • July 03: Epidemic declared over by WHO

  10. Timeline 774 Known Dead (9.1% fatality rate)

  11. The SARS Coronavirus (SARS-CoV) • Coronaviridae first identified in 1937 in chickens (avian infectious bronchitis) • Crown-shaped peplomers surrounding RNA source of name (Corona = Crown in Latin) • Responsible for common cold (2nd most common etiology after rhinoviridae) • Exact number unknown: many don’t grow in cultures • SARS virus can be grown in Vero culture (primate fibroblast cell line from 1962)

  12. Diagnosis: CDC Clinical Criteria • Asymptomatic or mild respiratory illness • Moderate respiratory illness • Temperature of >100.4°F (>38°C)*, and • One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia). • Severe respiratory illness • Temperature of >100.4°F (>38°C)*, and • One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia), and • radiographic evidence of pneumonia, or • respiratory distress syndrome, or • autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause

  13. Diagnosis: CDC Epidemiologic Criteria Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or previously documented or suspected community transmission of SARS (see Table below), or Close contact within 10 days (one incubation period) of onset of symptoms with a person known or suspected to have SARS. Table. Travel criteria for suspect or probable U.S. cases of SARS

  14. Diagnosis: CDC • Laboratory Criteria • Confirmed • Detection of antibody to SARS-associated coronavirus (SARS-CoV) in a serum sample, or • Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the • specimen and a different set of PCR primers, or Isolation of SARS-CoV. • Negative • Absence of antibody to SARS-CoV in a convalescent–phase serum sample obtained >28 days after symptom onset.** • Undetermined • Laboratory testing either not performed or incomplete. • Case Classification*** • Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria • for exposure; laboratory criteria confirmed or undetermined. • Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria • for exposure; laboratory criteria confirmed or undetermined.

  15. Diagnosis: WHO Suspect case 1.   A person presenting after 1 November 2002 with history of: -  high fever (>38 °C) AND -   cough or breathing difficulty AND one or more of the following exposures during the 10 days prior to onset of symptoms: -  close contact with a person who is a suspect or probable case of SARS; -  history of travel, to an area with recent local transmission of SARS -  residing in an area with recent local transmission of SARS 2.  A person with an unexplained acute respiratory illness resulting in death after 1 November 2002, but on whom no autopsy has been performed AND one or more of the following exposures during to 10 days prior to onset of symptoms: -  close contact with a person who is a suspect or probable case of SARS; -  history of travel to an area with recent local transmission of SARS -  residing in an area with recent local transmission of SARS

  16. Diagnosis: WHO Probable case 1.  A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR). 2.   A suspect case of SARS that is positive for SARS coronavirus by one or more assays. 3.   A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause. Exclusion criteria A case should be excluded if an alternative diagnosis can fully explain (his or her) illness.

  17. Clinical Manifestations • Incubation period: 2-10 days • Prodrome: 1-2 days • myalgia, fever, malaise • Fever > 38°C • Less commonly diarrhea • Respiratory Phase: 3-7 days after onset; lasts to day 11-14 • Cough, SOB, hypoxia • Severity varies • Falling SpO2 (<94%) ICU; SpO2 < 92% likely intubation • Entire illness lasts 3 weeks if you don’t die; ? long term effects Source: Loutfy, M, SARS: The Frontline Experience; Powerpoint presentation, 20 Oct 03

  18. Clinical Manifestations (cont’d) • Extreme anxiety out of proportion to hypoxia • Hyperglycemia • Thrombocytopenia • Leukopenia • Lymphopenia • Increased LDH, CK, ALT, lipase • Increased severity in elderly (up to 50% mortality > age 65); rare, less severe in children

  19. Radiologic findings CXR: focal or multifocal airspace disease/consolidation  bilateral ground glass opacities consistent with ARDS/SIRS; may be NORMAL High Contrast CT: can determine disease in patients with “normal” CXR; parenchymal and airspace disease evident

  20. Treatment • As of Nov 03, no specific treatment supportive • Antibiotics: azithromycin, ceftriaxone not useful against virus, may help if bacterial superinfection • High-dose steroids in China avascular necrosis, other side effects • Ribavirin used not recommended (hemolytic anemia) • Experimental: TNF-alpha, protease inhibitors…

  21. Lessons Learned from China and Canada Meta-Issues: • Misinformation • language issues, WHO travel warning in Toronto • Lack of Communication • between countries, governments, hospitals  public health authorities • Lack of Personnel • underfunded health care system; unions and contracts; overtime issues • Assumptions • Public health authorities assumed hospitals had adequate infection control • Transfers • ED  ward  long term care ED  other hospitals (lots of opportunities for infection) • Post-Traumatic Stress • Health-care workers, civilians; stigmatization of subsets of populace (e.g., Chinese) • Quarantine • Legal issues: Canada had no legal definition of quarantine pre-SARS; difficulties enforcing home quarantine (e-mail, phone, videophone to read thermometer); people will cheat and go to work if not given paid leave • No wakes, ritual washing of body caused stress

  22. Lessons Learned from China and Canada Hospital Infection Control: • Wash your hands! Alcohol denatures proteins– good vs. enveloped viruses • Single entry point for staff separate from patients • Guard with personal protective equipment (PPE) to prevent unauthorized entry • Non-critical hospital staff (med students)  stay home • Strict no visitor policy (difficult to enforce with hospital personnel patients) • N95 mask + gown + no beards among ED staff for all patients during outbreak • Change PPE after every high-risk encounter (respiratory dz vs. ankle fracture) • Care with pens/cell phones/computers/pagers • No hallway stretchers • No humidified oxygen or nebs or BiPAP in ED  send to ICU • Limit staff contacts to minimum required for care (hard with sick colleagues)

  23. Airway Management • High risk of transmission of SARS virus during airway manipulation/intubation • 5/50 intubations in Toronto  SARS transmitted  20 healthcare workers infected • Conflicts among staff to avoid being the laryngoscopist for high-risk patients • Intubation rarely emergency in SARS gradual decompensation over 12 hours should NOT be stat procedure (takes 5 minutes minimum to don appropriate protective equipment) • 10-20% of patients will need to be intubated

  24. High Risk Procedures • laryngoscopy • intubation • airway suctioning • neb treatment (use MDIs instead) • bronchoscopy (including fiberoptic intubation) • bagging via mask • emesis care • anything that causes patient to cough

  25. Intubation Guidelines • Plan ahead! Will take at least 5 minutes to… • Apply N95 mask, goggles, disposable footwear, gown, gloves, belt-mounted PAPR (powered air purifying respirator), head cover, extra gown, extra gloves; if no PAPR N95 mask, googles, disposable surgical cap, disposable full-face shield • Most experienced intubationist (not resident) Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718

  26. Intubation Guidelines (cont’d) • Avoid awake fiberoptic intubation; consider surgical airway • Plan for rapid sequence induction with skilled assistant available for cricoid pressure; be generous with sux unless contraindicated • Minimal bagging pre-intubation: 5 mins preox with 100% FiO2 • High-efficiency filter between facemask and bag • Intubate and confirm correct placement • Airway equipment sealed in double zip-locked bag and removed for decon • Careful degowning/gloving with help of assistant • Wash hands with alcohol-based cleanser prior to touching hair or face Reference: Anaesthesia and SARS, British Journal of Anaesthesia 90: 6, June 2003, 715-718

  27. Discussion Issues • Everyone should read intranet resource: HCW Surveillance Protocol for SARS– MGMC (links to CDC sources) • PAPR availability at MGMC: Ortho space suits are kept where? Available to ED? Do we need to buy more for ICU, ED? • Infectious Disease consultants: WRAMC. Phone #s in ICU, ED? • ICU beds rate limiting step– 22 beds in Toronto’s North York hospital maxed out…Transfer MOU with other hospitals? • Ambulance personnel trained/equipped (N95 masks, ?PAPR)? • Quarantine issues: If hospital quarantined, policies for paying contractors, etc.? Sleeping arrangements, food, water? • Training: Should we try a SARS drill starting from ED ICU  OR to see how we do? Probably as important as mock code blue

  28. Conclusions “The only thing we have to fear is LACK of fear itself” --former Deputy Treasury Secretary Lawrence Summers • SARS will recur– and may recur forever • SARS is a disease of healthcare workers out of proportion to the community • Until there is an effective treatment or vaccine, SARS will remain a life-threatening diagnosis • The intangible costs of SARS (economic, post-traumatic) may rival the obvious effects (morbidity, mortality); unknown long-term effects • Protecting healthcare workers from SARS is difficult– takes time, money, communication, planning, training, communication…

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