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      Safety sequence intubation: the 10 “P's” algorithm and cognitive aid for airway management in COVID-19 patients Translated title: Sequência de segurança de intubação: o algoritmo 10 “Ps” e ferramenta cognitiva para manuseio de vias aéreas em pacientes com COVID-19

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          Dear Editor, The past few months have shown an increasing incidence of transmission of SARS-CoV-2 from patients to health care providers (HCPs). Figures from China's National Health Commission show that more than 3300 HCP's had been infected as of early March. In Italy, 20% of responding health-care workers were infected. 1 It is important to protect staff from transmission during high-risk procedures like tracheal intubation. The cognitive aid (Fig. 1 ) formulated, suggests the following 10 P's as a series of steps for safety sequence intubation in Coronavirus Disease (COVID) 19 patients, with the intent to simplify the substantial amount of information currently related to COVID-19 in scientific literature. 1. Protection: All aerosol generating procedures (AGPs) are to be done in negative pressure isolation rooms with minimum personnel involved. WHO's interim guidance published on March 19th, on “Rational use of personal protective equipment for COVID-19” recommends, AGP-PPE to include respirator N95 or FFP2 standard, or equivalent, gown, gloves, eye protection and apron. 2 2. Planning: Assign roles and responsibilities, plan the airway management strategy before entering the isolation room. Quick airway assessment of the patient can be done using MACOCHA score. 3 Subsequently airway plan (plan A to plan D) can be tailored by the team to achieve successful intubation in the first attempt. The team members should practice closed loop communication and watch for cross-contamination. 3. Preparation: This step involves preparation of patient specific airway equipment kit and drugs outside the isolation room. Cricothyroidotomy kit can be kept outside with the runner. Once inside the isolation room, check and assemble equipment using mnemonic SOAP ME (Fig. 1). 4. Position: Appropriate positioning of the patient recommends 30-degree head up to improve oxygenation and ramp position in the obese to ease intubation. 5. Pre-oxygenation: An appropriately sized well-fitting mask applied to the patient's face using 2-person, 2-handed VE-grip for a better seal. 4 The preferable circuit is a closed dual limb circuit or rebreathing circuit like Mapleson's C (Waters’) or coaxial modification of Mapleson's D (Bain's). 6. Pre-treatment: Judicious hemodynamic resuscitation can be undertaken. 7. Pressure: We recommend it to be used only when a trained assistant is available as it can cause difficulty in glottis visualization if not properly applied. 8. Paralytics and induction: Purpose is to ensure adequate depth and avoid coughing. Avoid positive pressure ventilation before securing the airway to prevent potential aerosolization of virus present in the airway. 9. Placement of tube and confirmation: Laryngoscopy should be undertaken with the device most likely to achieve prompt first pass successful tracheal intubation. Using a video laryngoscope is recommended. Additional barrier like plastic sheet tent or box may be used. Use a standard failed tracheal intubation algorithm with a cognitive aid if difficulty arises. 10. Post-intubation management: Avoid circuit disconnection – push twist all connections. If the disconnection of circuit is warranted, then always disconnect with filter or apply tube clamp to the endotracheal tube before doing so. Seal all used airway equipment in a double zip-locked plastic bag. Clean the room 20 minutes after tracheal intubation (or last AGP). Fig. 1 Cognitive aid/checklist for safety sequence intubation in COVID-19 suspect or confirmed patient. PPE, Personal Protective Equipment; AMPLE, Allergies, Medication, Past history, Last meal, Events; RSI, Rapid Sequence Intubation; 2nd gen SAD, Second generation Supraglottic Airway Device; BMV, Bag Mask Ventilation; e- FONA (SBT), emergency Front of Neck access (scalpel-bougie-tube); HEPA, High Efficiency Particulate Air; DL, Direct Laryngoscope; VL, Video Laryngoscope; PPV, Positive Pressure Ventilation; NMB, Neuro Muscular Blockers. Airway management of COVID-19 patients involves specific challenges of risk of infection to HCPs and rapid desaturation of patients during apnea leading to added stress if patient's airway is not handled smoothly in the first attempt of intubation. The positive impact of cognitive aids and checklists in anesthesia has been investigated by a number of studies. 5 These studies have kept patient's safety as foremost priority. In conclusion, an adequate balance has to be maintained between the safety of HCPs and management of COVID-19 patients. Conflicts of interest The authors declare no have conflicts of interest.

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          Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).
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             M Fei,  J.L. Blair,  M.J. Rice (2017)

              Author and article information

              Braz J Anesthesiol
              Braz J Anesthesiol
              Brazilian Journal of Anesthesiology (Elsevier)
              Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda.
              15 October 2020
              15 October 2020
              India Institute of Medical Sciences, Department of Emergency Medicine, Rishikesh, India
              Author notes
              [* ]Corresponding author.
              © 2020 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda.

              Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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