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      Pediatric Airway Management in Coronavirus Disease 2019 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society

      research-article
      Author(s): , MBCHB, MMed, MHSC * , , , MD † , , MD, FRCPC ‡ , , MD § , , BMBS, FRCA * , , MD, FRCPC * , , MD ‖ , , MD , , MD # , , MD ** , , MD ** , , MD †† , , MD ‡‡ , , MBBS §§ , , MD ‖‖ , , MD, MBA ¶¶ , , MD ## , , MD ‡ , , MD ‡ , , MD ‡ , , MD ‡ , , MD, , MD † , , MD *** , , MD *** , , MD ††† , , MD ‡‡‡ , , MD §§§ , , MD ‖‖‖ , , MD ¶¶¶ , , MD ‖ , , MD ‖ , , MD ‖ , , MD ‖ , , MD ### , , MD **** , , MD †††† , , MD, MBA †††† , , MD ‡‡‡‡ , §§§§ , , MD ‖‖‖‖ , , MD ‖‖‖‖ , , MD ¶¶¶¶ , , MD #### , , MD #### , , MD ***** , , MD ††††† , , MD ‡‡‡‡‡ , , MD §§§§§ , , MD ‖‖‖‖‖ , , MD ¶¶¶¶¶ , , MD ¶¶¶¶¶ , ##### , , MD * , ##### , †††††† , , MD ‖‖ , , MD ####
      Publication date (Electronic):
      Journal: Anesthesia and Analgesia
      Publisher: Lippincott Williams & Wilkins

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          Abstract

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          Abstract

          The severe acute respiratory syndrome Coronavirus 2 (Coronavirus Disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

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          Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

          Neeltje van Doremalen, Trenton Bushmaker, Dylan H Morris … (2021)
          To the Editor: A novel human coronavirus that is now named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (formerly called HCoV-19) emerged in Wuhan, China, in late 2019 and is now causing a pandemic. 1 We analyzed the aerosol and surface stability of SARS-CoV-2 and compared it with SARS-CoV-1, the most closely related human coronavirus. 2 We evaluated the stability of SARS-CoV-2 and SARS-CoV-1 in aerosols and on various surfaces and estimated their decay rates using a Bayesian regression model (see the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org). SARS-CoV-2 nCoV-WA1-2020 (MN985325.1) and SARS-CoV-1 Tor2 (AY274119.3) were the strains used. Aerosols (<5 μm) containing SARS-CoV-2 (105.25 50% tissue-culture infectious dose [TCID50] per milliliter) or SARS-CoV-1 (106.75-7.00 TCID50 per milliliter) were generated with the use of a three-jet Collison nebulizer and fed into a Goldberg drum to create an aerosolized environment. The inoculum resulted in cycle-threshold values between 20 and 22, similar to those observed in samples obtained from the upper and lower respiratory tract in humans. Our data consisted of 10 experimental conditions involving two viruses (SARS-CoV-2 and SARS-CoV-1) in five environmental conditions (aerosols, plastic, stainless steel, copper, and cardboard). All experimental measurements are reported as means across three replicates. SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours), with a reduction in infectious titer from 103.5 to 102.7 TCID50 per liter of air. This reduction was similar to that observed with SARS-CoV-1, from 104.3 to 103.5 TCID50 per milliliter (Figure 1A). SARS-CoV-2 was more stable on plastic and stainless steel than on copper and cardboard, and viable virus was detected up to 72 hours after application to these surfaces (Figure 1A), although the virus titer was greatly reduced (from 103.7 to 100.6 TCID50 per milliliter of medium after 72 hours on plastic and from 103.7 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). The stability kinetics of SARS-CoV-1 were similar (from 103.4 to 100.7 TCID50 per milliliter after 72 hours on plastic and from 103.6 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). On copper, no viable SARS-CoV-2 was measured after 4 hours and no viable SARS-CoV-1 was measured after 8 hours. On cardboard, no viable SARS-CoV-2 was measured after 24 hours and no viable SARS-CoV-1 was measured after 8 hours (Figure 1A). Both viruses had an exponential decay in virus titer across all experimental conditions, as indicated by a linear decrease in the log10TCID50 per liter of air or milliliter of medium over time (Figure 1B). The half-lives of SARS-CoV-2 and SARS-CoV-1 were similar in aerosols, with median estimates of approximately 1.1 to 1.2 hours and 95% credible intervals of 0.64 to 2.64 for SARS-CoV-2 and 0.78 to 2.43 for SARS-CoV-1 (Figure 1C, and Table S1 in the Supplementary Appendix). The half-lives of the two viruses were also similar on copper. On cardboard, the half-life of SARS-CoV-2 was longer than that of SARS-CoV-1. The longest viability of both viruses was on stainless steel and plastic; the estimated median half-life of SARS-CoV-2 was approximately 5.6 hours on stainless steel and 6.8 hours on plastic (Figure 1C). Estimated differences in the half-lives of the two viruses were small except for those on cardboard (Figure 1C). Individual replicate data were noticeably “noisier” (i.e., there was more variation in the experiment, resulting in a larger standard error) for cardboard than for other surfaces (Fig. S1 through S5), so we advise caution in interpreting this result. We found that the stability of SARS-CoV-2 was similar to that of SARS-CoV-1 under the experimental circumstances tested. This indicates that differences in the epidemiologic characteristics of these viruses probably arise from other factors, including high viral loads in the upper respiratory tract and the potential for persons infected with SARS-CoV-2 to shed and transmit the virus while asymptomatic. 3,4 Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed). These findings echo those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial spread and super-spreading events, 5 and they provide information for pandemic mitigation efforts.
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            Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China

            Yuanyuan Dong, Xi Mo, Yabin Hu … (2020)
            To identify the epidemiological characteristics and transmission patterns of pediatric patients with the 2019 novel coronavirus disease (COVID-19) in China.
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              Chest CT for Typical 2019-nCoV Pneumonia: Relationship to Negative RT-PCR Testing

              Xingzhi Xie, Zheng Zhong, Wei Zhao … (2020)
              Some patients with positive chest CT findings may present with negative results of real time reverse-transcription–polymerase chain- reaction (RT-PCR) for 2019 novel coronavirus (2019-nCoV). In this report, we present chest CT findings from five patients with 2019-nCoV infection who had initial negative RT-PCR results. All five patients had typical imaging findings, including ground-glass opacity (GGO) (5 patients) and/or mixed GGO and mixed consolidation (2 patients). After isolation for presumed 2019-nCoV pneumonia, all patients were eventually confirmed with 2019-nCoV infection by repeated swab tests. A combination of repeated swab tests and CT scanning may be helpful when for individuals with high clinical suspicion of nCoV infection but negative RT-PCR screening
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                Author and article information

                Journal
                Journal ID (nlm-ta): Anesth Analg
                Journal ID (iso-abbrev): Anesth. Analg
                Journal ID (publisher-id): ANE
                Title: Anesthesia and Analgesia
                Publisher: Lippincott Williams & Wilkins
                ISSN (Print): 0003-2999
                ISSN (Electronic): 1526-7598
                Publication date (Print): 20 April 2020
                Publication date (Electronic): 13 April 2020
                Electronic Location Identifier: 10.1213/ANE.0000000000004872
                Affiliations
                From the [* ]Department of Anesthesia, The Hospital for Sick Children, Toronto, Ontario, Canada
                [† ]Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital of Boston, Harvard School of Medicine, Boston, Massachusetts
                [‡ ]Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
                [§ ]Department of Anesthesiology and Pain Management, Children’s Hospital of Cleveland Clinic, Cleveland, Ohio
                [‖ ]Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                []Department of Anesthesiology and Pain Management, University of Western Australia, Crawley, Australia
                [# ]Department of Anaesthesia and Pain Management, The Royal Children’s Hospital, Victoria, Australia
                [** ]Department of Anesthesiology, University of California at Los Angeles, Los Angeles, California
                [†† ]Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
                [‡‡ ]Department of Anesthesia, Alberta Children’s Hospital, Calgary, Alberta, Canada
                [§§ ]Department of Anesthesiology, BC Children’s Hospital, Vancouver, British Columbia, Canada
                [‖‖ ]Department of Anesthesiology; University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado
                [¶¶ ]Department of Anesthesiology, Lurie Children’s Hospital of Chicago, Chicago, Illinois
                [##x0023; ]Department of Anesthesiology, Shriners Hospitals for Children, Chicago, Illinois
                [*** ]Department of Pediatric Anesthesiology, University of Michigan Health Center, Ann Arbor, Michigan
                [††† ]Department of Anesthesiology, Weill Cornell Medical College, New York, New York
                [‡‡‡ ]Department of Anesthesiology, Duke University, Durham, North Carolina
                [§§§ ]Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest, North Carolina
                [‖‖‖ ]Department of Anesthesiology and Pain Medicine, Akron Children’s Hospital, Northeast Ohio Medical University, Akron, Ohio
                [¶¶¶ ]Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Ohio State University, Columbus, Ohio
                [### ]Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
                [**** ]Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children’s Health System of Texas, Dallas, Texas
                [†††† ]Department of Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
                [‡‡‡‡ ]Department of Anesthesiology, University of Texas Medical School at Houston, Houston, Texas
                [§§§§ ]Department of Anesthesia, Hospital Son Espases, Illes Balears, Spain
                [‖‖‖‖ ]Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
                [¶¶¶¶ ]Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
                [#### ]Department of Clinical Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                [***** ]Department of Anesthesiology, Instituto de Ortopedia Infantil Roosevelt, Bogotá, Colombia
                [††††† ]Department of Anesthesiology, University of Texas Southwestern Medical Center and Children’s Health System of Texas, Dallas, Texas
                [‡‡‡‡‡ ]Department of Anesthesiology and Pediatrics, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
                [§§§§§ ]Department of Anesthesiology, Children’s Hospital Los Angeles, Los Angeles, California
                [‖‖‖‖‖ ]Department of Anesthesiology, Arkansas Children’s Hospital & University of Arkansas & Medical Science Center, Little Rock, Arkansas
                [¶¶¶¶¶ ]Montreal Children’s Hospital, McGill University Health Center, McGill University, Montreal, Canada
                [###### ]/label>Pediatric Anesthesia Unit, Cardiac and Neonatal Section, Gregorio Marañón University Hospital, Madrid, Spain
                [****** ]Department of Otorhinolaryngology Head and Neck Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                [†††††† ]Department of Pediatric Anesthesia, Istituto Giannina Gaslini, Genova, Italy.
                Author notes
                Address correspondence to Clyde T. Matava, MBCHB, MMed, MHSC, Department of Anesthesia and Pain Medicine, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada. Address e-mail to clyde.matava@ 123456sickkids.ca .
                Article
                Accession ID: 00020
                DOI: 10.1213/ANE.0000000000004872
                PMC ID: 7173403
                PubMed ID: 32287142
                SO-VID: 0b29b80b-9559-4d59-a01c-04fc8bb9a0f2
                Copyright © Copyright © 2020 International Anesthesia Research Society
                License:

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                Date accepted : 10 April 2020
                Categories
                Subject: Pediatric Anesthesiology
                Subject: Special Article
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