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COVID-19 Resources

Tuesday, April 28, 2020

Index

We welcome submissions to continuously update this COVID-19 resource list. Please use the Index in the right column to quickly access a subject area. 
 

COVID-19, the novel coronavirus, was declared a pandemic on March 11th, 2020.

Italy, China, Spain, and other countries have seen unprecedented numbers of patients, overwhelming their healthcare systems due to a variety of factors.

Cardiothoracic surgery is one of the frontline specialties in the response to this pandemic: our patients and care-providers face very specific challenges.

Providing Care to COVID-19 Patients

  • Cardiothoracic surgery, anesthesiology, critical care and nursing providers, technicians, and advanced health care practitioners are particularly exposed to the risk of infection when intubating or performing bronchoscopy on COVID-19 patients.
  • Cardiothoracic surgeons provide specialized care, specifically in the form of temporary mechanical circulatory support (VA- and VV-ECMO) for patients with severe ARDS or cardiomyopathy due to COVID-19 that is refractory to maximum critical care support.
  • Cardiothoracic surgery patients are frequently older with multiple pre-existing other health conditions, so they are high-risk for susceptibility to severe forms of the COVID-19 infection pre- and post-operatively.
  • Cardiothoracic surgery programs face the unique challenge of performing emergency thoracic organ transplantation between potentially exposed or infected donors and recipients safely and effectively, and ensuring that postoperative patients on immunosuppression do not contract COVID-19.
  • Cardiothoracic surgery “elective” patients may face serious risk of adverse events while waiting for surgery, so they are disproportionately impacted by suspending normal elective operating schedules.
  • The ability to perform cardiac and thoracic surgery is limited by any reduction in ventilator or ICU bed availability
  • The needs are 24/7, and the COVID-19 response teams face fatigue and burn-out in addition to illness.

Much is unknown regarding how this pandemic will truly affect our specialty and healthcare system.  It is more important than ever that we as a specialty work together across institutions, our countries, and the world to share best practices, real time information, support, and strategies as to how to manage, mitigate, and flatten the spread of COVID-19. This resource has been put together with those goals.

KEY RESOURCES

The role of chest imaging during the COVID-19 pandemic is discussed in this CHEST Journal article. (posted on April 15)
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A new version of Johns Hopkins COVID-19 dashboard has just been released. This dashboard focuses on the United States and provides data and infographics not available on the global version. (posted April 14)
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Providers from Mount Sinai Health System in New York offer a protocol to repurpose noninvasive ventilators for invasive support of COVID-19 patients with acute hypoxemic respiratory failure. (posted April 8)
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COVID-19 for Healthcare Professionals App: The only app available for healthcare professionals to have all necessary COVID-19 resources in an easily accessible format. Article provides instructions to access app. (posted March 27)
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The American College of Surgeons provides triage guidelines for surgical care for elective cases during the COVID-19 pandemic. (posted March 25)
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The Canadian Journal of Anesthesia has provided succint recommendations and an infographic to outline the management of COVID-19 cases in the operating room. (posted March 25)
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GENERAL EDUCATIONAL RESOURCES

An article from the Journal of American College of Cardiology that discusses the characterization of myocardial injury in patients with COVID-19. (posted October 27, 2020)
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An overview of COVID-19 and cardiac surgery in a lower income country. (posted October 23, 2020)
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An excellent report on where we are headed with Covid-19. (posted on May 7)
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An online tool that models how lifting or extending different types of social distancing measures will affect states. (posted April 30)
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A timely World Journal of Pediatric and Congenital Heart Surgery article on outcomes measurement, transparency, and public reporting. (posted April 27)
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Comprehensive review of COVID-19 in the context of cardiac involvement, immunology, and therapeutic approach. (posted April 13)
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Guidance on how to organize second- and third-string teams using a detailed staff inventory. (posted April 8)
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Updated guidelines from the CDC on how to cope when mask quanity runs low. (posted April 8)
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COVID-19 Projection Model from the University of Washington's Institute for Health Metrics and Evaluation. This interactive site predicts the times of peak resource utilization, mortality, and cases over the next several months in each U.S. state. (posted April 6)
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An overview from The New Yorker about Hong Kong's and Singapore's successful approach to COVID-19. (posted March 27)
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JAMA Cardiology article discusses the association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. (posted March 26)
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The Faculty of Intensive Care Medicine, The Intensive Care Society, The Association of Anaesthetists, and the Royal College of Anaesthetists publishes COVID-19 clinical guidance for intensive care and anaesthetics. (posted March 23)
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A description on the seven Chinese coronavirus guidelines, filmed at the CCA and ACC COVID-19 Conference, March 18, 2020. (posted March 23)
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Guidelines from the Centers for Disease and Prevention for clinicians who may have been exposed to COVID-19. (posted March 22)
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Global research study regarding surgery and COVID-19 to learn ways to improve the quality, safety, and outcomes during the pandemic. (posted March 22)
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State and local level information regarding emergency declarations, state health initiatives, telemedicine. (posted March 22)
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Infographic providing country by country COVID-19 case trajectories. (posted March 22)
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An important paper from the Imperial College COVID-19 Response Team on which the UK has based its advice on the impact of non-pharmaceutical interventions.  (posted on March 20)
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The official Hong Kong Centre for Health Protection Guidelines for both the public and healthcare professionals. (posted on March 20)
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Official CDC Guidance 
General guidance for non-healthcare workers, including daily update on US cases, travel advice, social distancing, stocking supplies at home, “everyday precautions,” plan for if you get sick, when to call a doctor, and community support for older adults. (posted on March 19)
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Summary COVID-19 Primer for Intensivists 
One page primer by “A Seattle Intensivist” Nick Mark MD with bullet point summary of biology, epidemiology, diagnosis and prevention, labs and imaging, treatment, and prognosis. (posted on March 19)
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DIAGNOSIS AND MANAGEMENT RESOURCES

The role of chest imaging during the COVID-19 pandemic is discussed in this CHEST Journal article. (posted on April 15)
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In this CTSNet article, the authors describe their experience with a patient in their unit who had an air leak following thoracic surgery who was later found to have COVID-19. (posted April 9)
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An International Task Force composed of clinicians from academic centers active in COVID‐19 patient care. Consensus suggestions were derived using the electronic decision‐making portion of the Convergence of Opinion on Recommendations and Evidence (CORE) process. (posted April 7)
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This JAMA Cardiology series from Wuhan, China, suggests that myocardial injury has a significant association with fatal outcome of COVID-19, while the prognosis of patients with underlying CVD but without myocardial injury were relatively favorable. They conclude that it's reasonable to triage patients with COVID-19 according to the presence of myocardial injury for prioritized treatment and even more aggressive strategies. It is reasonable to triage patients with COVID-19 according to the presence of underlying CVD and evidence of myocardial injury for prioritized treatment and even more aggressive strategies. (posted April 2)
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"Protection of COVID-19 Medical Team in Wuhan" is a video on practical medical staff protection. (posted April 2)
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Bullet point guidelines for managing those who are critically ill, with quality of evidence and strength of recommendations graded. (posted March 27)
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A JAMA Network study describing the initial group of critically ill patients infected with SARS-CoV-2 in the United States. (posted March 26)
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The U.S. Food and Drug Administration’s letter to health care providers providing medical glove conservation strategies. (posted March 26)
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The CDC hosted a webinar on March 25 about optimization strategies for healthcare PPE. Slides and transcript are now available. (posted March 25)
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Infographic that offers details on the sequence for putting on and removing PPE. (posted March 22)
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Procedures to assist surgeons with guidance on managing non-emergent operations during the COVID-19 pandemic. (posted March 22)
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Strategies from the CDC for optimizing PPE, including eye protection, isolation gowns, facemasks, and N95 respirators. (posted March 22)  
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JAMA Network article on how to care for critically ill patients with COVID-19. (posted March 22)
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The University of Wisconsin medicine policies regarding COVID-19. The policies continue to evolve on a daily basis. (posted on March 20)
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The New England of Journal of Medicine published an article on the clinical characteristics of COVID-19. (posted on March 20)
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The Chinese Medical Association has published the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7), currently considered as the most authoritative and comprehension protocol in China, is based on the medical community’s experiences and researches. (posted on March 20)
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Clinical Review of COVID-19 and the ICU 
A useful review of ICU clinical presentation, diagnosis, and management of COVID-19 patients, including ICU preparedness, based on initial experience from China and France, published 26th February 2020. This is now well known but helpful summary. (posted on March 19)
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Early Experience During an Emergency Response in North Italy 
A highly relevant JAMA Network summary of lessons from the ICU response in North Italy to COVID-19, including strategies to increase regional ICU capacity, triage and containment efforts, pattern of admissions to ICU in first two weeks of epidemic and projections for increased ICU demand. Written on February 21st with projections out to March 20th, 2020. Key lessons: (posted on March 19)

  • Laboratory capacity to test for SARS-CoV-2 should have been increased immediately
  • A large dedicated COVID-19 facility should have been converted more quickly, in addition to the surge ICU response. Increasing ICU capacity is not enough.

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What to Do With COVID-19 Cases in the Operating Room

One detailed workflow slide from the Hendren Project outlining roles of OR personnel (nurse in charge, OR runner / circulator, OR nurse, anesthesiologist or anesthesia nurse, and OR technician in the OR) during preparation phase, intra-operative phase, post-operative phase, and follow-up. (posted on March 19)

Guidance in disinfection:

  • Chlor-Clean: Floor, all furniture surfaces including OR table, stools
  • Virex 256: PAPR
  • MikroidL Computer screens and medical equipment
  • Alcholol wipe: Goggles
  • Airing of OR not required.
  • Removal of PPE and PAPR guidance

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What We Do When a COVID-19 Patient Needs an Operation 
One Hendren Project summary slide listing nine bullet points covering operating room preparation, PPE, transport including dedicated transport ventilator, induction wearing powered air-purifying respirator (PAPR) cleaning, and hydrogen peroxide vaporizer to decontaminate. (posted on March 19)
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CTSNet Roundtable
Brian Mitzman, Assistant Professor of Cardiothoracic Surgery at NYU Langone Health, moderates a discussion on the COVID-19 pandemic with an international group of physicians currently on the front lines. (posted on March 18)
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ECMO

An article from The Lancent Respitory Medicine covering the treatment for severe acute respiratory distress syndrome. (posted March 26)
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ELSO (Extracorporeal Life Support Organization) COVID-19 Resource 
Great online resource from ELSO including detailed guidelines on use and experience of VV-ECMO  and VA-ECMO in COVID patients. Translations in Italian, Spanish, French, Chinese, Arabic, and Japanese. Updated with recommendations from CDC, WHO, information on clinical trials (the ECMOCARD study), and outcomes. It also includes great summary graphics, and links to all the COVID-19 resources on the major journal sites, including NEJM, JAMA, Science, and The Lancet. (posted on March 19)
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Role of ECMO in COVID-19 
A broad editorial from two Singapore and New York centers on the role of ECMO in COVID-19. The JAMA Network content does not include information on experience or outcomes but instead focuses on resource allocation implications. (posted on March 19) 
Key takeaways:

 

TRANSPLANT

Global Transplantation COVID Report March 2020: This report is a detailed compilation of various transplantation experiences during different phases of the COVID-19 epidemic around the world, published by the Transplantation Society in the journal Transplantation. (posted April 6)
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American Society of Transplantation FAQ for Transplant Professionals 
Includes guidance on transplant in patients with active or recent COVID-19 (recommending two negative COVID PCRs) and information on whether to screen living and deceased donors including use of FDA emergency application for COVID testing. (posted on March 19)
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Donor Management 
Transplant centers should monitor the CDC map of confirmed cases closely. The location of the donor in addition to the travel history of the donor will play a large role in the decision to test the donor prior to procurement. (posted on March 19)
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The Association of Organ Procurement Organizations (AOPO) has indicated that donors who test positive for COVID-19 are medically ineligible for organ donation.  If testing is available and a donor tests negative, the donor may be considered for organ donation.  Finally, donor deferral may be considered medically appropriate if testing is not immediately available in the situation of a potentially high risk donor or one experiencing symptoms.
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Due to the unprecedented nature of this pandemic, there is scant literature to guide best practices.  The Sichuan Provincial People’s Hospital in China recently published a letter describing their experience with organ donation during COVID-19. 
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Recipient Management 
While we do not know specific information yet about the severity of COVID-19 in transplant recipients when compared to the standard population, we do know that other viruses do cause more severe disease in transplant patients. Extrapolating this, it is of utmost importance that our recipients take appropriate precautions to prevent infection. (posted on March 19)

The American Society of Transplantation has provided the following information which is pertinent for transplant recipients and institutions that hospitalize and care for transplant recipients regarding COVID-19 here:

View Article

The Journal of Heart and Lung Transplantation (JHLT) has published the first cases of COVID-19 in heart transplant recipients in China.  This article notes the importance of holding baseline immunosuppression, treating with high dose corticosteroids and pooled immunoglobulins in addition to empiric moxifloxacin and ganciclovir in these cases.
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Transplant Healthcare / Procurement Team Management 
This area is rapidly evolving. Utilizing the CDC map and correlating with donor location will determine the individual teams’ ability, as well as institutional policies regarding travel and procurement practices.  Personal protective equipment as detailed in the links above should be utilized no matter the location or circumstance. (posted on March 19)

FIRST-HAND EXPERIENCES 

 

It’s perfectly human to be concerned about your health and safety during the first major pandemic in recent history. This resource is for the people coping with the mental and emotional realities of these challenging times. We make sure that all the medical professionals on the front line share advice to help inspire and enable self-care during the pandemic. (posted on August 25)
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An article sharing clinical observations on proning to prevent the vent and intubating a colleague. (posted on April 8)
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Former AATS President Dr. Craig Smith updates his 'Department of Surgery family' at Columbia University each day, highlighted as "Winston Churchill's radio speeches of this war." A refreshing reality check from the background noise. (posted April 2)
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"Severe COVID-19: Frontline ICU Experience From Wuhan and Shanghai," a video sharing insights of treating patients with severe COVID-19. (posted April 2)
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An ER doctor from Elmhurst Hospital in Queens, NY, describes how the staff scrambles with the surge of coronavirus patients and the lack of tools they need. (posted March 27)
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A first-hand experience, described in ProPublica, about lung failure in young COVID-19 patients. (posted March 27)
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Outbreak, First Response, and Lessons 
Great infographics from the North Italian COVI-19 network discussions. (posted on March 19)
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Personal Accounts
Detailed observations of the typical clinical course written by an intensivist in the Seattle area, including description of sudden lethal myocarditis, often occurring after apparent improvement in ventilatory status, and a response to comments by a physician in one of the hardest hit centers in Italy.
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ICU PREPAREDNESS

These are short lectures from the CORE Curriculum Review course in cardiovascular and thoracic surgery held each September in Salt Lake City, Utah. These four lectures review cardiovascular physiology, pharmacology, critical care topics, and surgical intervention for heart failure. (posted March 27):
Cardiovascular Physiology View Article
Cardiovascular Pharmacology View Article
Critical Care Physiology View Article
Acute Heart Failure View Article

Society of Critical Care Medicine COVID-19 Online Resource (posted on March 19) 
Great collection of resources, including:

  • Checklists and detailed guidance for how to prepare an ICU (Also available in Spanish)
  • Guidance on how to increase ICU capacity for COVID-19
  • Statistics on US ICU beds and ventilators and supply versus demand
  • Guidance on ICU staffing models to expand care beyond the traditional ICU
  • Disaster triage
  • COVID-19 webcasts
  • Training modules – including sustained ventilation outside ICU

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JAMA Network
Editorial describing the Kaiser-Permanente experience with COVID-19 mitigation, based on the assumption that the containment is no longer possible because of extensive silent community spread. (posted on March 19) 
Guidance includes:

  • Asymptomatic or mildly symptomatic patients recommended to stay home until symptoms improve. No SARS-CoV-2 testing recommended.
  • Remote care delivered via telephone/video for mild increase in symptoms.
  • Healthcare personnel with workplace exposure to suspected or confirmed COVID-19-like illness to self-monitor for symptom onset or possible testing.
  • Health care personnel with COVID-19-like illness symptoms but test negative remain off work until resolution of fever or improvement in other symptoms.

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ETHICS

A JAMA network article about off-label drug use, compassionate use, and randomized clinical trial during COVID-19. (posted March 27)
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A frank, eye-opening discussion from the New England Journal of Medicine on allocating scarce resources in a time of pandemic. (posted March 26)
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A thoughtful commentary about the need for a triage committee to determine the optimal allocation of ventilators in a time of competing needs. (posted March 26)
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Drs. Daniel Drake and Robert Sade, along with other members of the Cardiothoracic Ethics Forum and several nonmember experts, produced a paper on the ethical considerations for cardiothoracic surgeons in pandemics. (posted March 25)
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Clinical Ethics Recommendations for the Allocation of Intensive Care in Exceptional, Resource-Limited Circumstances (posted on March 19) 
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