In Response.

Abstract

We appreciate the wisdom and experience shared by our colleagues in Italy, one of the earliest hardest-hit areas. We enjoy this opportunity to reply to the thoughtful critique from Sorbello et al.1 We do not have a dedicated intubation location. Intubations typically occur in a cohorted intensive care unit with negative pressure rooms, but might occur in the emergency department or at any location during cardiac arrest. When requested, a coronavirus disease 2019 (COVID-19) rapid response team is activated and summoned to the patient room. This team is comprised of 2 intensive care nurses, a respiratory therapist, and the on-call anesthesiologist. Our preassembled airway kit described in “Your COVID-19 Intubation Kit,”2 enters the room, allowing our anesthesiologist to efficiently proceed with intubation. The code blue cart containing additional airway supplies, a defibrillator, and additional resuscitation medications is brought by the rapid response team each time an intubation occurs. Sorbello et al1 note the absence of rescue airway items in our kit. Additional endotracheal tube sizes, supraglottic airways, endotracheal tube introducers, and a surgical airway kit are available in intensive care units, the emergency department, and the code blue cart. The advantage of this setup is that the items that are most likely required are present in our mobile kit, and we do not introduce surplus supplies into a contaminated environment. A requisite to this setup is excellent communication between the inside and outside of the room for the time-sensitive delivery of critical supplies. We optimize our communication by delegating a point person to obtain the needed supplies and have begun trialing a high-fidelity 2-way communication telemedicine device with audio and video capabilities to facilitate communication between our in-room and out-of-room team members. They also recommend end-tidal capnography. We agree and include end-tidal capnography lines in the kit, which are compatible with our intensive care unit monitors or defibrillators. The sample line is included in our figure.2 A bougie-loaded endotracheal tube was recommended during all videolaryngoscopy attempts. As this is not standard practice at our institution, we do not recommend universal application of this technique, but recognize its utility and defer to each provider. They further propose cohorting all intubations to a dedicated spot, where patients are transported for the sole purpose of intubation, to then be returned to an intensive care unit. This cohorting provides teams with the essential and rescue supplies for airway and hemodynamic resuscitation. It is advantageous to the anesthesiologists by providing a controlled environment, to the patient by optimizing robust resuscitation management, and to the system by encouraging early and continuous assessment of patients potentially requiring intubation. At least in our institutional layout, we have the following concerns with a designated intubation location. Additional time is expended preparing and transferring to this location and can potentially delay the timeliness of an early intubation. The intubation spot requires elective transport of a critically ill hypoxemic patient who might have additional monitoring or respiratory therapy needs. Transport itself is a time fraught with patient complications in critically ill patients, with a high incidence of respiratory events and other adverse events.3–6 Infectious concerns also accompany this approach. Elective transportation to the intubation spot will increase exposure to noninfected staff and patient spaces via direct and indirect contact, droplet, and aerosol,7 especially when done under urgent or emergent conditions. Additionally, this dedicated COVID intubation spot would be exposed to high viral contact, presumably contaminating equipment and supplies, and thus should be limited to only confirmed COVID patients. If used in unconfirmed COVID status patients, the room itself can propagate the spread of disease via indirect contact. Strict infection control may mitigate these risks. Because inherent differences exist in each hospital, each institution must develop an individualized response that fits their needs. The additional ideas presented by Sorbello et al1 are appreciated; “thinking together”8 strengthens our response to the evolving and complex problems of COVID-19. Roberto A. Lopez, MDLeila Zuo, MDT. Miko Enomoto, MDMichael F. Aziz, MDDepartment of Anesthesiology & Perioperative MedicineOregon Health & Health Sciences UniversityPortland, Oregon[email protected]