Alfred Sacchetti

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).

OBJECTIVE: Exclusion of family members (FM) during pediatric procedures in the emergency department (ED) is an accepted practice. This study questions the validity of such a practice. SUBJECTS: FM of ED pediatric patients undergoing procedures and ED staff performing procedures. SITES: ED of a tertiary care university-affiliated community hospital and the pediatric ED of a university hospital. METHODS: Post-procedure surveys were obtained from FM remaining with their child during an ED procedure and from the ED personnel performing the procedures. FM activity during the procedure was also recorded. RESULTS: Ninety-six children (average age 20 months) underwent a total of 127 procedures. ED procedures included: vascular access 91, lumbar puncture 23, urethral catheterization 9, nasogastric tube placement 1, rapid sequence intubation 1, fluid resuscitation from shock 1, and removal of foreign body from eye 1. Three children were critically ill during performance of procedures. ED staff answered 98 surveys concerning the performance of the 127 procedures. FM ACTIVITIES INCLUDED: Stood at bedside 35 (31%), soothed child 21 (19%), and helped restrain child 55 (55%). In 55 (57%) cases the FM was the only adult present with the ED staff member performing the procedure(s). FM MEMBER OPINIONS OF PRESENCE DURING PROCEDURES WERE: Good idea 101 (91%), bad idea 6 (5%), and did not care 4 (4%). ED staff opinions were: good idea 92 (93%), bad idea 2 (2%), and did not care 4 (5%). FM presence made four (5%) members of the ED staff nervous. CONCLUSION: FM presence during ED procedures is a practice favored by both parents and ED staff at our institutions. This practice should not be limited to minimally invasive procedures in stable patients but should be considered for procedures such as lumbar punctures and intubations even in critically ill patients.