Critical Care During the Coronavirus Crisis: Challenges and Considerations for the Cardiothoracic and Vascular Anesthesia Community

Abstract

THE CORONAVIRUS pandemic has challenged healthcare globally, resulting in more than 1 million cases worldwide with an estimated mortality rate of 5% to 10%.1Phua J, Weng l, Ling L, et al. Intensive care management of coronavirus disease (COVID-19): Challenges and recommendations [e-pub ahead of print]. Lancet Resp Med. doi: 10.1016/S2213-2600(20)30161-2, Accessed 10 April 2020.Google Scholar,2He H, Zhao S, Han L, et al. Anesthetic management of patients undergoing aortic dissection repair with suspected severe acute respiratory syndrome coronavirus-2 infection [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.021, Accessed 10 April 2020.Google Scholar Although the clinical presentation is often mild- to- moderate in severity, many will develop critical disease that requires admission to an intensive care unit.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar The severe clinical presentations in coronavirus disease-2019 (COVID-19) include acute respiratory distress syndrome, cardiogenic shock, septic shock, disseminated intravascular coagulation, and renal failure.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar, 6Zhao S Ling K Yan H et al.Anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedures.J Cardiothorac Vasc Anesth. 2020; 34: 1125-1131Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 7Augoustides JG.Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.001, Accessed 10 April 2020.Google Scholar The novelty of this infection, its infectious potential, and its clinical consequences have generated a surge in demand for critical care services that include unique considerations for echocardiography and extracorporeal membrane oxygenation (ECMO), both in adult and pediatric practice.5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar, 6Zhao S Ling K Yan H et al.Anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedures.J Cardiothorac Vasc Anesth. 2020; 34: 1125-1131Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 7Augoustides JG.Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.001, Accessed 10 April 2020.Google Scholar, 8Augoustides JG.Perioperative echocardiography – key considerations during the coronavirus pandemic [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.046, Accessed 10 April 2020.Google Scholar, 9Dalia AA Ortoleva J Fiedler A et al.Extracorporeal membrane oxygenation is a team sport: Institutional survival benefits of a formalized ECMO team.J Cardiothorac Vasc Anesth. 2019; 33: 902-907Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The purpose of this freestanding editorial is to highlight the challenges and considerations in the critical care response to COVID-19. The suggested strategies have outlined options for designing best practices to navigate the coronavirus crisis successfully. The provided references also can serve as a guide for policy leaders to frame their plans for meeting the demands of the pandemic at their respective institutions. The hazards of advanced airway management, including endotracheal intubation, in patients with COVID-19 include infection as a result of the aerosolization of viral particles.10Weixia Li, Huang J, Guo X, et al. Anesthesia management and perioperative infection control in patients with the novel coronavirus [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.035, Accessed 12 April 2020.Google Scholar The focus on infection control during airway management in this setting for patients includes limited mask ventilation, full barrier precautions, limited operators, and dedicated airway teams.11He Y, Wei J, Bian J, et al. Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019 [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.026, Accessed 12 April 2020.Google Scholar,12Tan Z, Phoon PHY, Zeng LA, et al. Response and operating room preparation for the COVID-19 outbreak: A perspective from the National Heart Centre Singapore [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.050, Accessed 12 April 2020.Google Scholar These important considerations apply to all aerosolizing procedures, including bronchoscopy and transesophageal echocardiography, and the clinical care of these patients in the interventional suite and operating room environments.10Weixia Li, Huang J, Guo X, et al. Anesthesia management and perioperative infection control in patients with the novel coronavirus [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.035, Accessed 12 April 2020.Google Scholar, 11He Y, Wei J, Bian J, et al. Chinese Society of Anesthesiology expert consensus on anesthetic management of cardiac surgical patients with suspected or confirmed coronavirus disease 2019 [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.026, Accessed 12 April 2020.Google Scholar, 12Tan Z, Phoon PHY, Zeng LA, et al. Response and operating room preparation for the COVID-19 outbreak: A perspective from the National Heart Centre Singapore [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.050, Accessed 12 April 2020.Google Scholar, 13Augoustides JG.Perioperative echocardiography during the coronavirus crisis – considerations in pediatrics and congenital heart disease [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.022, Accessed 12 April 2020.Google Scholar The leadership of ECMO services during this pandemic should design strategies to manage the personnel, equipment, facilities, and support systems for this life-saving therapy.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar,14Ramanathan K, Antognimi D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases [e-pub ahead of print]. Lancet Resp Med. doi: 10.1016/S2213-2600(20)30121-1, Accessed 12 April 2020.Google Scholar,15MacLaren G, Fisher D, Brodie D, et al. Preparing for the most critically ill patients with COVID 19: The potential role of extracorporeal membrane oxygenation [e-pub ahead of print]. JAMA. doi: 10.1001/jama.2020.2342, Accessed 12 April 2020.Google Scholar Although ECMO has been recommended in patients with COVID-19 by the World Health Organization, recent guidelines from the Extracorporeal Life Support Organization have highlighted that this modality should be used in experienced centers as a rescue strategy for severe acute respiratory distress syndrome.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar Despite the initial recommended approaches for acute respiratory distress syndrome associated with COVID-19, overall oxygenation may deteriorate clinically as reflected by a decreasing blood oxygen tension/inspired oxygen ratio.14Ramanathan K, Antognimi D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases [e-pub ahead of print]. Lancet Resp Med. doi: 10.1016/S2213-2600(20)30121-1, Accessed 12 April 2020.Google Scholar,15MacLaren G, Fisher D, Brodie D, et al. Preparing for the most critically ill patients with COVID 19: The potential role of extracorporeal membrane oxygenation [e-pub ahead of print]. JAMA. doi: 10.1001/jama.2020.2342, Accessed 12 April 2020.Google Scholar When this important ratio decreases to less than 150 mmHg, it should trigger consideration of the following acute care interventions to improve gas exchange: lung recruitment maneuvers, positive end-expiratory pressure titration, neuromuscular blockade, and prone positioning.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar Inhaled selective pulmonary vasodilators such as nitric oxide and epoprostenol may be considered in specialized centers to further optimize matching of ventilation and perfusion throughout ventilated lung areas.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar If this ratio decreases to less than 75 mmHg for 3- to- 6 hours and/or the arterial pH persists at less than 7.25 with a carbon dioxide tension more than 60 mmHg despite maximal medical therapy, then ECMO should be considered.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar The contraindications for ECMO in patients with COVID-19 should be hospital-specific, with consideration of local factors such as team experience and resource availability.14Ramanathan K, Antognimi D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases [e-pub ahead of print]. Lancet Resp Med. doi: 10.1016/S2213-2600(20)30121-1, Accessed 12 April 2020.Google Scholar,15MacLaren G, Fisher D, Brodie D, et al. Preparing for the most critically ill patients with COVID 19: The potential role of extracorporeal membrane oxygenation [e-pub ahead of print]. JAMA. doi: 10.1001/jama.2020.2342, Accessed 12 April 2020.Google Scholar Clinical risk factors such as advanced age, frailty, prior lung disease, diabetes, heart failure, and immunosuppression also may qualify as contraindications to ECMO.14Ramanathan K, Antognimi D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases [e-pub ahead of print]. Lancet Resp Med. doi: 10.1016/S2213-2600(20)30121-1, Accessed 12 April 2020.Google Scholar, 15MacLaren G, Fisher D, Brodie D, et al. Preparing for the most critically ill patients with COVID 19: The potential role of extracorporeal membrane oxygenation [e-pub ahead of print]. JAMA. doi: 10.1001/jama.2020.2342, Accessed 12 April 2020.Google Scholar, 16Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study [e-pub ahead of print]. Lancet Respir Med. doi: 10.1016/S2213-2600(20)30079-5, Accessed 12 April 2020.Google Scholar The indications and contraindications to ECMO during the coronavirus crisis should be adjusted in real time to local factors. The cardiovascular challenges associated with COVID-19 are significant and merit specific focus by the acute care teams that may include members of the cardiothoracic and vascular anesthesia community.7Augoustides JG.Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.001, Accessed 10 April 2020.Google Scholar The coronavirus infection may directly infect the heart and result in acute myocarditis with cardiogenic shock and pericarditis with effusion and tamponade.7Augoustides JG.Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.001, Accessed 10 April 2020.Google Scholar The clinical spectrum of cardiac involvement in severe COVID-19 includes acute coronary syndromes, clinically significant arrhythmias, right ventricular failure, and/or vasoplegic shock from multiple etiologies including patient-specific and virus-specific factors.4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed April 8, 2020.Google Scholar, 6Zhao S Ling K Yan H et al.Anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedures.J Cardiothorac Vasc Anesth. 2020; 34: 1125-1131Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 7Augoustides JG.Cardiovascular consequences and considerations of coronavirus infection – perspectives for the cardiothoracic anesthesiologist and intensivist during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.001, Accessed 10 April 2020.Google Scholar These cardiac manifestations often can be diagnosed with serial bedside echocardiography by experienced operators who have adapted the conduct of the examination to these challenging circumstances.8Augoustides JG.Perioperative echocardiography – key considerations during the coronavirus pandemic [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.03.046, Accessed 10 April 2020.Google Scholar,13Augoustides JG.Perioperative echocardiography during the coronavirus crisis – considerations in pediatrics and congenital heart disease [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: 10.1053/j.jvca.2020.04.022, Accessed 12 April 2020.Google Scholar In the event of cardiac arrest, the conduct of advanced life support in adults, children, and neonates can be challenging and requires significant adjustments.17Sommer P, Lukovic E, Fagley E, et al. Initial clinical impressions of the critical care of COVID-19 patients in Seattle, New York City, and Chicago [e-pub ahead of print]. Anesth Analg. doi: 10.1213/ANE.0000000000004830, Accessed 12 April 2020.Google Scholar, 18Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. 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Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047463, Accessed 12 April 2020.Google Scholar,19De Filippis EM, Ranard LS, Berg DD. Cardiopulmonary resuscitation during the COVID-19 pandemic: A view from trainees on the frontline [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047260, Accessed 12 April 2020.Google Scholar As a response to this call for a national conversation, the American Heart Association recently updated its guidelines for basic and advanced life support in light of COVID-19.18Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047463, Accessed 12 April 2020.Google Scholar This multisociety guideline recommended multiple adjustments to the protocols for cardiopulmonary resuscitation in 3 major categories as follows: (1) minimize provider exposure, (2) emphasize airway and ventilation strategies to minimize aerosolization risk, and (3) consider the appropriateness of resuscitation.18Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047463, Accessed 12 April 2020.Google Scholar,19De Filippis EM, Ranard LS, Berg DD. Cardiopulmonary resuscitation during the COVID-19 pandemic: A view from trainees on the frontline [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047260, Accessed 12 April 2020.Google Scholar In the first group of considerations about exposure control, this guideline recommended clear and comprehensive communication, protocols for limiting personnel, meticulous use of personal protective equipment, and consideration of mechanical devices for chest compressions.18Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047463, Accessed 12 April 2020.Google Scholar In the second group of considerations about control of aerosolization, the guideline recommended airway filters, lower thresholds for endotracheal intubation, video laryngoscopy, experienced operators, limiting of bag-and-mask ventilation, and minimizing disconnects of the closed circuit components.18Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047463, Accessed 12 April 2020.Google Scholar In the third group of considerations about appropriateness of resuscitation, the expert consensus recommended that the goals of care be addressed whenever possible, including institutional indications for cardiopulmonary resuscitation in COVID-19.18Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians [e-pub ahead of print]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.047463, Accessed 12 April 2020.Google Scholar This clarification about goals of care may require input from the palliative care service in selected cases as part of a systematic institutional response to the COVID-19 pandemic.20Ross SW, Lauer CW, Miles WS, et al. 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Preparation for possible sustained transmission of 2019 novel coronavirus: Lessons from previous epidemics.JAMA. 2020; 323: 1129-1130Crossref PubMed Scopus (71) Google Scholar In the event of cardiogenic shock refractory to medical management, consideration of mechanical circulatory support could be made, including venoarterial ECMO.3Augoustides JG.Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis [e-pub ahead of print]. J Cardiothorac Vasc Anesth. doi: doi:10.1053/j.jvca.2020.03.060, Accessed 10 April 2020.Google Scholar, 4Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed April 8, 2020.Google Scholar, 5World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected—interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-c