Arizona Hospitals and Health Systems’ Statewide Collaboration Producing a Triage Protocol During the COVID-19 Pandemic

Patricia A. Mayer, MD

David H. Beyda, MD

C. Bree Johnston, MD

Department of Bioethics and Medical Humanism and Medicine, The University of Arizona College of Medicine-Phoenix, Phoenix, AZ USA

Abstract

We describe the process by which all hospitals and health systems in Arizona, normally competitors, rapidly cooperated to develop a statewide protocol delineating how to allocate scarce resources during the COVID-19 pandemic should triage be required anywhere in the state. Eight physician ethicists from seven different health systems created the Addendum* (see editor's note after Abstract), which was accepted by all hospitals and health systems, approved by the State Disaster Medical Advisory Committee (SDMAC), and then formally adopted by the Arizona Department of Health Services (ADHS). In addition, the entire state developed a plan to “stick together” such that no facility would be forced to triage unless all were overwhelmed. Because we are unaware of any other state’s hospitals and health systems producing and committing to a shared triage protocol and plan, we believe this experience can serve as a model for other locales during the absence of sufficient state or federal guidance.

Editor's Note

The Addendum initially posted on ADHS has been removed. It appears to have been altered including removal of the authors. To see the original Addendum click here.

Abbreviations

• ADHS: Arizona Department of Health Services
• CMO: Chief Medical Officer
• CSC: Arizona Crisisi Standards of Care Plan, 3rd edition 
• SDMAC: State Disaster Medical Advisory Committee

The Challenge

Potential shortages of ventilators and other scarce resources during COVID-19 compelled creation of plans to allocate resources fairly (1). Without protocols, resources would be allocated on a first come first serve basis, which is inefficient and ethically problematic (1-4). Without a cohesive state plan, public confusion combined with uneven resources could lead to “hospital shopping” with vastly different individual outcomes that would likely benefit patients with greater social or economic advantages and be determined by geography rather than medical criteria.  

The Goal  

Because the existing Arizona Crisis Standards of Care Plan, 3^rd edition (CSC, 2) was deemed too non-specific to apply usefully in the pandemic, representatives from hospitals and hospital systems across the state, including small rural hospitals, competing private hospital systems, and  federal agencies (Indian Health Service and the Veteran’s Administration) sought a common triage protocol to addend the CSC. The goal was to create  a protocol accepted by  all hospitals, health care systems and ADHS.

Background

The pandemic caused severe and previously unknown shortages of personal protective equipment and life-sustaining equipment and therapies (6).  Much has been written about the need to allocate scarce resources in a manner that is fair, consistent, and based on sound ethical principles. Multiple states, cities, and health systems have shared their processes and protocols for triage during the pandemic (7,8)  However, integration between disparate systems has proved challenging at both the local, state and federal levels. Arizona is the sixth largest state in the country and the fourteenth most populous, with five-sixths of the population concentrated in two main metropolitan areas:Phoenix and Tucson. In addition, Arizona is home to twenty-one Native American tribes/nations. Most of the state is rural, distances from populated areas to health care facilities can be great, and access to health care is unevenly distributed. In Arizona health insurance coverage of the population is 45.1% employer, 5.2% non-group, 21% AHCCCS (Arizona’s Medicaid equivalent), 21.6% Medicare, 1.5% Military, and 11.1% uninsured (9).

Triage ethics differ from “usual” clinical ethics in which the lens is the individual patient and all patients have access to life-sustaining treatments.  hen life-sustaining resources are insufficient (e.g., pandemics, war), the concentration of the lens shifts from the individual good to the greater community (10). This shift is not only challenging for health care workers but also for a society that is increasingly divided and distrustful of experts. Therefore, it was clear that any protocol had to be fair, transparent and uniform across the state in order to be  and acceptable. This necessitated cooperation between organizations traditional in competition with each other that lacked a solid framework for this kind of emergency cooperation.

Creation and Adoption

In the early months of 2020, New York City and Italy were epicenters of the pandemic, and the world watched as they were overwhelmed with cases causing a shortage of beds and personal protective equipment. In response, Arizona hospitals health systems rapidly   their existing triage protocols and the state CSC. Therefore, amid predictions for a major surge in Arizona by summer 2020, Phoenix area hospital chief medical officers (CMOs) created the Triage Collaborative.  The first meeting laid a foundation for seamless collaboration since all participants, CMOs or their physician designees, were empowered to make decisions during the meetings without delay . This framework, uniquely possible due to the acute time pressure of the pandemic, enabled broader, more streamlined collaboration than had previously been possible between organizations that were normally in competition.

At the second meeting a week later, with representatives from the entire state  ADHS proposed a “Surge Line”. This 24/7 state-run hotline accessible to all Arizona healthcare providers   rapid transfers of COVID-19 patients to needed levels of care possible due to its ability to monitor statewide resource availability. All agreed to take part in the Surge Line, and it was rapidly implemented (11) Notably, and critical to success of the Surge Line, participation  was mandated and insurers  required to cover transfers and COVID-19 treatment at in-network rates by the Governor’s Executive Order 2020-38 in late May (12).  

On April 9, the Governor issued Executive Order 2020-27 which called for immunity from civil liability “in the course of providing medical services in support of the State’s public health emergency for COVID-19… (including) triage decisions…based on…reliance of mandatory or voluntary state-approved protocols …” (13). This  the necessity of a state-approved protocol. ADHS agreed to consider any protocol presented to them by the medical community.  

Driven by that Order, the Collaborative immediately shifted from sharing individual protocols to developing the needed statewide protocol  In addition, the Collaborative committed to cooperation agreeing that no facility would have to triage unless the entire state was overwhelmed  (14). To create the protocol  writing group of eight  from seven different systems volunteered to begin work immediately.

The writing goup reviewed the existing CSC and individual system protocols for suitability and agreed a new protocol was required that would be transparent, ethically sound  and reflect current best practices. After reviewing protocols from other states and literature on triage ethics, the group agreed on  goal: maximize the number of lives saved while treating patients without discrimination.

ADHS convened the State Disaster Medical Advisory Committee (SDMAC) in mid-June where the Addendum was discussed and approved.  ADHS then accepted and published the final COVID-19 Addendum: Allocation of Scarce Resources for Acute Care Facilities (15). The SDMAC was reconvened again in late June and recommended activation of the CSC, including the Addendum. The formal activation of the CSC by the Governor and ADHS on June 29 was unprecedented and signaled the ability to proceed with triage per the Addendum if needed. Arizona experienced its first major surge shortly thereafter, in July 2020. (for Timeline see Table 1 below).

Ethical Considerations

After a great deal of discussion, the writing group agreed on several key concepts:

1. Goals of care should be assessed as the first step in triage so that patients who do not desire ventilators or ICU beds will not compete for scarce resources that are unwanted (10).
2. The best available acute assessment score (e.g., SOFA, PELOD) should be utilized as an initial triage tool but should not be used alone (6-8).
3. Limited life expectancy should be included as a triage factor.
4. The protocol should avoid categorical exclusions and instead be based on prioritization criteria.
5. Perceived quality of life should not be considered.
6. The value of all lives must be explicitly recognized with triage criteria never used to deny resources when they are not scarce.
7. Criteria is only to prioritize patients when resources are scarce.
8. Criteria must not include any ethically irrelevant discriminatory criteria including race, ethnicity, national origin, religion, sex, disability, age, or gender identity.
9. Patients should be re-assessed and re-prioritized periodically based on their clinical course and continued likelihood of benefit.
10. Where “ties” occur in priority scores, the group must agree on which other factors to consider.
11. An explicit statement rejecting reallocation of personal/home ventilators (or any other durable medical equipment) in order to further protect patients with chronic respiratory conditions or disabilities was essential.

The Process

Bringing together the various health systems was remarkably seamless . However, the group faced a tight timeline to complete the protocol to prepare for a potential emergency.

Although members of the writing group agreed on the primary goal (e.g., maximizing number of lives saved), reaching consensus on other principles (e.g., how to incorporate life expectancy, life cycle, and instrumental concerns) was more challenging. However, over a short but intense time, members were able to reach decisions that all “could live with”.

Previous articles have advocated considering not only the number of lives saved using an acute assessment tool but incorporating other considerations, such as maximizing the number of years of life saved and using life cycle considerations (19,20). While the writing group agreed, members expressed concern about possible unintended consequences with those criteria. First, groups that have faced institutional racism and lifelong health disparities were more likely to have a shorter life expectancy and could face “double jeopardy” in triage protocols, particularly if comorbidities more prevalent in communities of color were used (21-4). Likewise, older patients would often be disadvantaged with these criteria. Group members felt strongly that use of life-years saved should be tempered to address these concerns and so elected to include near term life expectancy and the Life Cycle principle. Other issues included whether and how to prioritize pediatric patients, pregnant women, and single caretakers (25,26).

The group did agree to prioritize healthcare and other frontline workers in case of equal scores, not because of greater estimation of “worth” but because of the instrumental value they serve in the community and as an acknowledgement of their increased risk.

While the writing group did resolve issues in a way all parties “could live with”, members recognized ongoing discussions and updates would be important. For instance, after our Addendum was created, a strong case was made that triage policies should also promote population health outcomes and mitigate health inequalities (23). We echo the need to grapple with how best to address these equity and justice concerns. And although no protocol can perfectly reconcile all tensions we hope the Addendum reflects our sincere attempt to balance competing considerations fairly, ethically, and in a way that could be widely implemented if needed.  

The Team 

Arizona demonstrated a collaboration between all its hospitals and health systems with a subgroup of physician-ethicist representatives writing, employees at ADHS formatting and supporting the work, the SDMAC endorsing it, and the ADHS then accepting and publishing the Addendum with the agreement of the Governor’s’ office.

The Follow-up 

Arizona survived both the July 2020 and the January 2021 surges without resorting to triage and all hospitals and health systems continue to cooperate. The state Surge Line continues to function and as of Feb 1 had transferred over 3700 patients across the state. We remain acutely aware of the ongoing challenges of public perception, news reports, and social media, particularly in a society as divided as the U.S. is today. Already, the Addendum has been mis-characterized on social media as allowing health care providers to refuse scarce resources to older people and those with disabilities. We particularly hope that further conversations occurring outside the acute impending emergency will allow time for public engagement, which will provide valuable input and may mitigate inaccurate perceptions of the criteria used. Meantime, we believe our statewide transparent approach, with the support of ADHS, provided a novel approach and contributed to the state avoiding triage during the worst of our surges.

Conclusion

We believe the cooperation of   in developing a shared triage Addendum  represents a unique contribution and may provide a model for other localities facing public health emergencies requiring rapid decisive action.

References

1. ADHS. COVID-19 Addendum: Allocation of Scarce Resources in Acute Care Facilities, Recommended for Approval by State Disaster Medical Advisory Committee (SDMAC) 6/12/2020.  Available at https://www.azdhs.gov/documents/preparedness/epidemiology-disease-control/infectious-disease-epidemiology/novel-coronavirus/sdmac/covid-19-addendum.pdf.
2. Ventilator allocation guidelines. Albany: New York State Task Force on Life and the Law, New York State Department of Health, November 2015 , available at https://www.health.ny.gov/regulations/task_force/reports_publications/#allocation
3. Ferraresi M. A coronavirus cautionary tale from Italy: don’t do what we did. Boston Globe. March 13, 2020.  Available at https://www.bostonglobe.com/2020/03/13/opinion/coronavirus-cautionary-tale-italy-dont-do-what-we-did/
4. Sprung CL, Danis M, Iapichino G, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med. 2013 Nov;39(11):1916-24. [CrossRef] [PubMed]
5. ADHS. Arizona Crisis Standard of Care Plan, 3rd ED. 2020; Available at: https://www.azdhs.gov/documents/preparedness/emergency-preparedness/response-plans/azcsc-plan.pdf
6. Ranney ML, Griffeth V, Jha AK. Critical Supply Shortages - The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic. N Engl J Med. 2020 Apr 30;382(18):e41. [CrossRef] [PubMed]
7. Berger JT. Imagining the unthinkable, illuminating the present. J Clin Ethics. 2011 Spring;22(1):17-9. [PubMed]
8. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020 May 12;323(18):1773-1774. [CrossRef] [PubMed]
9. KFF Health Policy Analysis, State Health Facts, accessed March 15, 2020  at https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22arizona%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
10. Berger JT. Imagining the unthinkable, illuminating the present. J Clin Ethics, 2011. 22(1): 17-9.
11. Villarroel L, Christ, CM, Smith L et al. Collaboration on the Arizona Surge Line:  How Covid-19 Became the Impetus for Public, Private, and Federal Hospitals to Function as One System. NEJM Catalyst, Jan 21, 2021, available at https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0595
12. Office of Governor Doug Ducey. Executive Order: 2020-38: Ensuring Statewide Access to Care for COVID-19 Arizona Surge Line. AZ Governor. Published May 28, 2020.
13. Office of Governor Doug Ducey. Executive Order : 2020-27: The “Good Samaritan” Order Protecting Frontline Healthcare Workers Responding to the COVID-19 Outbreak”. AZ Governor. Published April 9, 2020.
14. Feldman SL, Mayer PA. Arizona Health Care Systems’ Coordinated Response to COVID-19-“In It Together”. JAMA Health Forum. Published online August 24, 2020. [CrossRef]
15. ADHS. COVID-19 Addendum: Allocation of Scarce Resources in Acute Care Facilities, Recommended for Approval by State Disaster Medical Advisory Committee (SDMAC) 6/12/2020.  Available at https://www.azdhs.gov/documents/preparedness/epidemiology-disease-control/infectious-disease-epidemiology/novel-coronavirus/sdmac/covid-19-addendum.pdf
16. Lambden S, Laterre PF, Levy MM, Francois B. The SOFA score-development, utility and challenges of accurate assessment in clinical trials. Crit Care. 2019 Nov 27;23(1):374. [CrossRef] [PubMed]
17. Leteurtre S, Duhamel A, Salleron J, Grandbastien B, Lacroix J, Leclerc F; Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP). PELOD-2: an update of the PEdiatric logistic organ dysfunction score. Crit Care Med. 2013 Jul;41(7):1761-73. [CrossRef] [PubMed].
18. Straney L, Clements A, Parslow RC, Pearson G, Shann F, Alexander J, Slater A; ANZICS Paediatric Study Group and the Paediatric Intensive Care Audit Network. Paediatric index of mortality 3: an updated model for predicting mortality in pediatric intensive care*. Pediatr Crit Care Med. 2013 Sep;14(7):673-81. [CrossRef] [PubMed]
19. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020 May 12;323(18):1773-1774. [CrossRef] [PubMed]
20. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020 May 21;382(21):2049-2055. [CrossRef] [PubMed]
21. Cleveland Manchanda E, Couillard C, Sivashanker K. Inequity in Crisis Standards of Care. N Engl J Med. 2020 Jul 23;383(4):e16. [CrossRef] [PubMed]
22. Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med. 2020 Jun 25;382(26):2534-2543. [CrossRef] [PubMed]
23. White DB, Lo B. Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic. Am J Respir Crit Care Med. 2021 Feb 1;203(3):287-295. [CrossRef] [PubMed].
24. Yancy CW. COVID-19 and African Americans. JAMA, 2020. 323(19): 1891-1892. [CrossRef] [PubMed]
25. Antommaria AH, Powell T, Miller JE, Christian MD; Task Force for Pediatric Emergency Mass Critical Care. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011 Nov;12(6 Suppl):S163-8. [CrossRef] [PubMed]
26. Beyda DH. Limited Intensive Care Resources: Fair is What Fair Is Current Concepts in Pediatric Critical Care by the Society of Critical Care Medicine (2015 Edition): 55-59.
27. White DB, Lo B. Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic. Am J Respir Crit Care Med, 2021. 203(3): 287-295.

Acknowledgments

The authors would like to acknowledge ADHS as well as all of their collaborators from the Arizona hospitals and health systems including Abrazo Healthcare and Carondelet Healthcare Phoenix, Tucson & Nogales; Banner Health System; Canyon Vista Medical Center; CommonSpirit Arizona Division Dignity Health; Havasu Regional Medical Center; Honor Health; Indian Health Service; Kingman Regional Medical Center; Northern Arizona HealthCare; Phoenix Children’s Hospital; Summit Healthcare; Tucson Regional Medical Center; University of Arizona College of Medicine; Veteran’s Administration; Valleywise Health; Yavapai Regional Medical Center; Yuma Regional Medical Center.

Cite as: Mayer PA, Beyda DH, Johnston CB. Arizona Hospitals and Health Systems’ Statewide Collaboration Producing a Triage Protocol During the COVID-19 Pandemic. Southwest J Pulm Crit Care. 2021;22(6):119-26. doi: https://doi.org/10.13175/swjpcc014-21 PDF

Ultrasound for Critical Care Physicians: Sometimes It’s Better to Be Lucky than Smart

Robert A. Raschke MD and Randy Weisman MD

Critical Care Medicine

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

We recently responded to a code arrest alert in the rehabilitation ward of our hospital. The patient was a 47-year-old man who experienced nausea and diaphoresis during physical therapy. Shortly after the therapists helped him sit down in bed, he became unconsciousness and pulseless. The initial code rhythm was a narrow-complex pulseless electrical activity (PEA). He was intubated, received three rounds of epinephrine during approximately 10 minutes of ACLS/CPR before return of spontaneous circulation (ROSC), and was subsequently transferred to the ICU.

Shortly after arriving, a 12-lead EKG was performed (Figure 1), and PEA recurred.

Figure 1. EKG performed just prior to second cardiopulmonary arrest showing S1 Q3 T3 pattern (arrows).

Approximately ten-minutes into this second episode of ACLS, a cardiology consultant informed the code team of an S1,Q3,T3 pattern on the EKG. A point-of-care (POC) echocardiogram performed during rhythm checks was technically-limited, but showed a dilated hypokinetic right ventricle (see video 1).

Video 1. Echocardiogram performed during ACLS rhythm check: Four-chamber view is poor quality, but shows massive RV dilation and systolic dysfunction.

Approximately twenty-minutes into the arrest, 50mg tissue plasminogen activator (tPA) was administered, and return of spontaneous circulation (ROSC) achieved two minutes later. A tPA infusion was started. The patient’s chart was reviewed. He had received care in our ICU previously, but this wasn’t immediately recognized because he had subsequently changed his name of record to the pseudonym “John Doe” (not the real pseduonym), creating two separate and distinct EMR records for the single current hospital stay. Review of the first of these two records, identified by his legal name, revealed he had been admitted to our ICU one month previously for a 5.4 x 3.6 x 2.9 cm left basal ganglia hemorrhage. We stopped the tPA infusion.

On further review of his original EMR is was noted that two weeks after admission for intracranial hemorrhage, (and two weeks prior to cardiopulmonary arrest), he had experienced right leg swelling and an ultrasound demonstrated extensive DVT of the right superficial femoral, saphenous, popliteal and peroneal veins. An IVC filter had been due to anticoagulant contraindication. The patient’s subsequent rehabilitation had been progressing well over the subsequent two weeks and discharge was being discussed on the day cardiopulmonary arrest occurred.

On post-arrest neurological examination, the patient gave a left-sided, thumbs-up to verbal request. Ongoing hypotension was treated with a norepinephrine infusion and inhaled epoprostenol. An emergent head CT was performed and compared to a head CT from four weeks previously (Figure 2), showing normal evolution of the previous intracranial hemorrhage without any new bleeding. 

Figure 2. CT brain four weeks prior to (Panel A), and immediately after cardiopulmonary arrest and administration of tPA (Panel B), showing substantial resolution of the previous intracranial hemorrhage.

A therapeutic-dose heparin infusion was started. An official echo confirmed the findings of our POC echo performed during the code, with the additional finding of McConnell’s sign. McConnell’s sign is a distinct echocardiographic finding described in patients with acute pulmonary embolism with regional pattern of right ventricular dysfunction, with akinesia of the mid free wall but normal motion at the apex (1). A CT angiogram showed bilateral pulmonary emboli, and interventional radiology performed bilateral thrombectomies. Hypotension resolved immediately thereafter. The patient was transferred out of the ICU a few days later and resumed his rehabilitation.

A few points of interest:

• IVC filters do not absolutely prevent life-threatening pulmonary embolism (2,3).
• Sometimes, serendipity smiles, as when the cardiologist happened into the room during the code, and provided an essential bit of information.
• Emergent POC ultrasonography is an essential tool in the management of PEA arrest of uncertain etiology.
• Barriers to access of prior medical records can lead to poorly-informed decisions. But in this case, ignorance likely helped us make the right decision.
• Giving lytic therapy one month after an intracranial hemorrhage is not absolutely contra-indicated when in dire need.
• As the late great intensivist, Jay Blum MD used to say: “Sometimes it’s better to be lucky than smart.”

References

1. Ogbonnah U, Tawil I, Wray TC, Boivin M. Ultrasound for critical care physicians: Caught in the act. Southwest J Pulm Crit Care. 2018;17(1):36-8. [CrossRef]
2. Urban MK, Jules-Elysee K, MacKenzie CR. Pulmonary embolism after IVC filter. HSS J. 2008 Feb;4(1):74-5. [CrossRef] [PubMed]
3. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005 Jul 19;112(3):416-22. doi: [CrossRef] [PubMed]

Cite as: Raschke RA, Weisman R. Ultrasound for Critical Care Physicians: Sometimes It’s Better to Be Lucky than Smart. Southwest J Pulm Crit Care. 2021;22(6):116-8. doi: https://doi.org/10.13175/swjpcc016-21 PDF 

High Volume Plasma Exchange in Acute Liver Failure: A Brief Review

Matthew D Rockstrom, MD¹

Jonathan D Rice, MD^1,2

Tomio Tran, MD³

Anna Neumeier, MD^1,4

¹Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA

²Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO USA

³Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA USA

⁴Department of Medicine, Division of Pulmonary Sciences and Critical Care, Denver Health and Hospital Authority, Denver, CO USA

Abstract

Acute liver failure (ALF) is characterized by acute liver injury, coagulopathy, and altered mental status. Acetaminophen overdose contributes to almost half the cases of ALF in the United States. In the era of liver transplantation, mortality associated with this condition has improved dramatically. However, many patients are not transplant candidates including many who present with overt suicide attempt from acetaminophen overdose. High volume plasma exchange (HVP) is a novel application of plasma exchange. Prior research has shown that HVP can correct the pathophysiologic derangements underlying ALF. A randomized control trial demonstrated improved transplant-free survival when HVP was added to standard medical therapy. In this case, we examine a patient who presented to the intensive care unit with ALF caused by intentional acetaminophen overdose. She was denied transplant due to overt suicide attempt, was treated with HVP, and made a rapid recovery, eventually discharged to inpatient psychiatry and then home.

Abbreviations: ALF: acute liver failure: CVVH: continuous veno-venous hemodialysis; DAMPs: damage associated molecular patterns; FFP: fresh frozen plasma; HVP: high volume plasma exchange; MODS: multisystem organ dysfunction; NAC: N-acetyl cysteine; NNT: Number needed to treat; SIRS: systemic inflammatory response syndrome; SMT: standard medical therapy; TNF-α: tumor necrosis factor alpha

Introduction

Acute liver failure (ALF) is a rare, life-threatening condition. Although survival has improved in the transplant era, mortality remains high without transplantation. Here we discuss a novel therapy for ALF patients which may provide improved transplant-free mortality.

Case Report

A 21-year-old woman arrived by ambulance, found to be obtunded and hypotensive in the field, with an empty bottle of acetaminophen and a suicide note. She had a history of depression, infrequent alcohol and marijuana use, and was otherwise healthy.

Upon presentation, she was afebrile (temperature 36.5°C), tachycardic (heart rate 155 beats-per-minute) and hypotensive requiring norepinephrine of 0.1 μg/kg/min to maintain mean arterial blood pressure above 65.  Due to grade IV encephalopathy, she was intubated.  Admission lab work is shown below (Table 1). Viral hepatitis and HIV serologies were negative and ultrasound demonstrated patent vasculature and normal liver parenchyma.

Table 1: Lab work on admission, hospital day 2, and following high-volume plasma exchange therapy.

BUN: blood urea nitrogen, AST: aspartate aminotransferase; ALT: alanine aminotransferase; INR: international normalized ratio; APAP: N-acetyl-para-aminophenol

N-acetyl cysteine (NAC) was administered and transplant evaluation was obtained. Despite meeting King’s College Criterion for transplantation, she was declined due to presentation for suicide attempt. She was managed supportively with vasopressors, continuous veno-venous hemodialysis (CVVH), and high-volume plasma exchange (HVP) at a rate of 8 liters of fresh frozen plasma (FFP) daily, receiving 24 liters total. After initiation of HVP, vasopressors were immediately weaned. The following day, her encephalopathy improved, and she followed simple commands. CVVH was discontinued on hospital day 4. She was extubated on hospital day 6 and was eventually discharged home.

Clinical Discussion

ALF is a life-threatening syndrome characterized by acute liver injury, encephalopathy, and coagulopathy. In the United States, the most common etiology is acetaminophen overdose, accounting for ~46% of cases (1). Standard medical therapy (SMT) is supportive, treating the underlying etiology and mitigating manifestations of multisystem organ dysfunction (MODS). The advent of transplantation dramatically improved the mortality associated with ALF but the benefit of transplant must be balanced with high-risk surgery, lifelong immunosuppression, and organ scarcity (2). Given these risks, patients undergo evaluation including psychologic evaluation which commonly excludes patients presenting with intentional acetaminophen overdose. Without transplantation, mortality for these patients remains high.

The pathophysiology of ALF is not entirely understood but is largely driven by hepatic necrosis leading to hepatic metabolic dysfunction and release of intracellular contents. Intracellular damage associated molecular pattern (DAMPs) and Kupffer cell activation trigger the release of pro-inflammatory cytokines like tumor necrosis factor alpha (TNF-α), which result in systemic inflammatory response syndrome (SIRS) and vasodilation (3,4). Subsequent hepatic metabolic dysfunction is manifested by hyperbilirubinemia, hyperammonemia, coagulopathy, and hypoglycemia.

High volume plasma exchange (HVP) has shown promise as a new modality of treatment for patients with ALF. A new implementation of plasma-exchange therapy, patient plasma is exchanged with donor FFP. In one prospective, randomized control trial by Larsen et al, 15% of ideal body weight of FFP was exchanged daily for three days in addition to SMT. HVP plus SMT improved survival to discharge when compared to SMT alone (58.7 % versus 47.8%, respectively; number needed to treat (NNT) 9.2) (5). HVP plus SMT has been shown to reverse clinical parameters associated with ALF including INR, bilirubin, vasopressor requirements, reliance on renal replacement, hepatic encephalopathy (5-7). HVP was also shown to significantly attenuate DAMPs, including IL-6 and TNF-α, indicating an ability to attenuate the biochemical nidus of MODS (6,7). A systematic review of HVP found evidence of mortality benefit in HVP for both ALF and acute on chronic liver failure, though Larsen et al remains the only randomized prospective trial. Subsequently, HVP has become a level I, grade 1 recommendation in European guidelines for ALF (6).

There are limitations associated with HVP including utilization of FFP, concerns for precipitation volume overload, and worsening cerebral edema. Additionally, there is no clear optimal regimen for dose and duration of HVP. In a recent randomized control trial by Maiwall et al, standard volume plasma exchange was shown to improve transplant free survival using only 1.5 to 2 times calculated patient plasma volume (4).

Conclusion

In this case, a 21-year-old patient presented with ALF following acetaminophen overdose. Despite qualifying for transplantation, she was denied due to presentation for suicide attempt. She was treated with standard medical therapy and HVP and had rapid improvement in hemodynamics and mentation. While it is impossible to quantify the degree to which HVP contributed to her recovery, her clinical improvement was dramatic despite presentation with severe disease. HVP has been shown to reverse the pathophysiologic hallmarks of ALF, improve transplant-free mortality, and is now a level I recommendation according to European guidelines. More trials are necessary to determine the optimal dose and duration of this life saving modality.

References

1. Lee WM. Etiologies of acute liver failure. Semin Liver Dis. 2008 May;28(2):142-52. [CrossRef] [PubMed]
2. Lee WM, Squires RH Jr, Nyberg SL, Doo E, Hoofnagle JH. Acute liver failure: Summary of a workshop. Hepatology. 2008 Apr;47(4):1401-15. [CrossRef] [PubMed]
3. Chung RT, Stravitz RT, Fontana RJ, Schiodt FV, Mehal WZ, Reddy KR, Lee WM. Pathogenesis of liver injury in acute liver failure. Gastroenterology. 2012 Sep;143(3):e1-e7. [CrossRef] [PubMed]
4. Maiwall R, Bajpai M, Singh A, Agarwal T, Kumar G, Bharadwaj A, Nautiyal N, Tevethia H, Jagdish RK, Vijayaraghavan R, Choudhury A, Mathur RP, Hidam A, Pati NT, Sharma MK, Kumar A, Sarin SK. Standard-Volume Plasma Exchange Improves Outcomes in Patients With Acute Liver Failure: A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2021 Jan 29:S1542-3565(21)00086-0. [CrossRef] [PubMed]
5. Larsen FS, Schmidt LE, Bernsmeier C, et al. High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol. 2016 Jan;64(1):69-78. [CrossRef] [PubMed]
6. Tan EX, Wang MX, Pang J, Lee GH. Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review. World J Gastroenterol. 2020 Jan 14;26(2):219-245. [CrossRef] [PubMed]
7. Larsen FS, Ejlersen E, Hansen BA, Mogensen T, Tygstrup N, Secher NH. Systemic vascular resistance during high-volume plasmapheresis in patients with fulminant hepatic failure: relationship with oxygen consumption. Eur J Gastroenterol Hepatol. 1995 Sep;7(9):887-92. [PubMed]

Cite as: Rockstrom MD, Rice JD, Tran T, Neumeier A. High Volume Plasma Exchange in Acute Liver Failure: A Brief Review. Southwest J Pulm Crit Care. 2021;22(5):102-5. doi: https://doi.org/10.13175/swjpcc009-21 PDF

April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman

Mohammad Abdelaziz Mahmoud, MD, DO

Andrea N. Pruett, BS

Emanuel Medical Center

Turlock, CA 95382

History of Present Illness

A 29-year-old healthy woman, who is 8 weeks postpartum, presented to the emergency department with severe shortness of breath, fast shallow breathing, nausea, several episodes of nonbloody nonbilious emesis, abdominal pain and malaise for 1 week. The patient delivered a healthy boy at full-term by spontaneous vaginal delivery. Her pregnancy was uneventful. She denied smoking or use of alcohol.

Physical Exam

On presentation to the emergency department her blood pressure was found to be 121/71, temperature 36.8°C, pulse 110 beats per minute, respiratory rate 20 breaths per minute and SpO2 saturation of 99% while breathing ambient air. Physical exam was remarkable except for dry mucous membranes, sinus tachycardia, and tachypnea with mild epigastric tenderness with light palpation.

Which of the following should be done? (Click on the correct answer to be directed to the second of five pages)

1. Complete blood count (CBC)
2. Metabolic panel
3. Chest x-ray
4. Arterial blood gases (ABGs)
5. All of the above

Cite as: Mahmoud MA, Pruett AN. April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman. Southwest J Pulm Crit Care. 2021;22(4):81-85. doi: https://doi.org/10.13175/swjpcc007-21 PDF.

First-Attempt Endotracheal Intubation Success Rate Using A Telescoping Steel Bougie

Evan D. Schmitz, MD

La Jolla, CA USA

Kevin Park, MD, MBA, FCCP 

MLK Community Medical Group

Compton, CA USA 

Abstract

Background

There has been a renewed interest in using the plastic intubation bougie to facilitate first-attempt endotracheal intubation success. The sterile single-use telescopic steel bougie (AIROD) was invented to overcome the limitations of the plastic bougie which is easily deformed during storage.  

Methods

This is a retrospective study involving critically ill patients who were intubated with the AIROD in the intensive care unit at a single institution. The purpose of this case series is to compare the success rate of the AIROD to the generally accepted success rate for the traditional plastic bougie of 96%.

Results

A total of 54 patients were enrolled at a single ICU over a 10 months period. All patients were critically ill with 76% having a difficult airway, Cormack-Lehane grade view 2 or greater in 60%, and ARDS secondary to COVID-19 in 54%. The primary outcome of first-attempt intubation success in critically ill patients intubated in the ICU with the AIROD was 97% with a 95% confidence interval of 0.89 to 0.99. The average time for intubation of all airway classifications was 15 seconds.

Conclusion

The AIROD first-attempt intubation success rate was found to be similar to the rate for the traditional plastic bougie.

Introduction

The BEAM (Bougie Use in Emergency Airway Management) trial, renewed interest in the use of a bougie rather than a stylet (1). In the BEAM trial, first-attempt endotracheal intubation success using a plastic bougie was compared to a stylet during laryngoscopy in an emergency department. First-attempt success was achieved in in 98% compared to 87% in all patients. In patients with at least one difficult airway characteristic, first-pass success using a plastic bougie was 96% compared to 82% using a stylet.

In 2019, the sterilized single-use telescopic steel bougie, AIROD (AIRODMedical; FL, USA), was introduced to the USA market (Figure 1).

Figure 1. A: AIROD closed. B: AIROD open. C: AIROD with an endotracheal tube loaded on the distal end.

The thin surgical steel construction of the AIROD allows it to bend slightly while maintaining its integrity to help manipulate oropharyngeal tissue without causing trauma. The AIROD can guide a 6.5 mm or larger endotracheal tube into the trachea. To do so, the AIROD is introduced into the oropharynx alongside a laryngoscope, either direct or video, and advanced just past the vocal cords. An endotracheal tube is then slid down over the AIROD and into the trachea securing the airway to allow for mechanical ventilation. The AIROD telescopes from one foot when closed to two feet when opened, offering many storage options.

Several publications have demonstrated that the AIROD is a safe and effective tool for endotracheal intubation (2-5). In this manuscript we extend those observations.

Methods

A retrospective analysis of all endotracheal intubations that were performed with the AIROD in the ICU at a single institution (Mercy One Hospital in Sioux City, IA) between October 18, 2020 and January 1, 2020 were included.

A successful first-attempt intubation was defined as the placement of an endotracheal tube into the trachea upon the initial insertion of the laryngoscope into the oropharynx. If the laryngoscope had to be removed and a second-attempt performed, it was considered a failure. Airways were graded using the Cormack-Lehane grade view (Appendix 1).

A difficult airway was defined as the presence of body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, stiff neck or the need for cervical spine immobilization (2). Intubation time was defined as the time from insertion of the laryngoscope to placement of an endotracheal tube with its cuff inflated.

Results

Patient characteristics are shown in Table 1. 

Table 1. Characteristics and outcomes of the critically ill patients intubated with the AIROD in the ICU.

A total of 54 patients with an average age of 62 years were included in the study. All patients were in critical condition. The average patient was obese with a BMI of 31.2 kg/m2. A difficult airway was present in 76% of the patients and 54% of the patients had COVID-19 infection. In total, 63% of the patients were male and 37% were female. Using the Cormack-Lehane grade view: 20% had a grade 4 view, 10% had a grade 3 view, and 30% had a grade 2 view.

Intubation first-attempt success rate was 97%. Subgroup analysis of first-attempt intubation success using the AIROD to intubate in patients with a difficult airway was 96%.

The average intubation time in the patients that were timed was 15 seconds (33/54 patients were timed). Of the patients with a difficult airway, the average time to intubate was also 15 seconds.

A bronchoscopy performed on 17% of the patients just after intubation revealed no evidence of tracheobronchial trauma.

Discussion

The patients intubated with the AIROD in the ICU had a first-attempt success rate of 97%. The first-attempt success rate for endotracheal intubation of the critically ill has been reported at only 70% (6,7). This corresponds to an absolute risk reduction of 27% in failure to intubate patients during the first-attempt with the use of the AIROD during the intubation of patients in critical condition.

Even when compared to patients who were not critically ill and were intubated with a plastic bougie in the emergency department in the BEAM trial (1), the first-attempt success rate with the AIROD was 97% vs. 98. In those patients who were critically ill and also had a difficult airway, the first-attempt intubation success rate with the AIROD was at 97% vs. 96% in all patients (not just the critically ill) with a difficult airway.

In this study, the average time to intubation in all critically ill patients was 15 seconds using the AIROD. For those patients who were critically ill and had a difficult airway, the time to intubation was also 15 seconds. A previous publication on consecutive COVID-19 patients with ARDS intubated using the AIROD also had an intubation time of 15 seconds (2). In the BEAM trial, the median time to intubation using the plastic bougie in all types of patients intubated in the emergency department was 38 seconds (1). In all critically ill patients, the AIROD was 23 seconds faster. Intubation with the AIROD took 40% of the time in those patients who were critically ill, including those with a difficult airway, as opposed to the plastic bougie. The decrease in time securing the airway may have an impact on overall decompensation and possible outcomes of the disease process. Further studies between low intubation time and disease outcome remain an area to be studied in the future. The decrease in intubation time using the AIROD was not accompanied by adverse events such as cardiac arrest or tissue damage.

During multiple intubations, the AIROD was used to lift the epiglottis and move the oropharyngeal tissue that was obscuring the vocal cords out of the way, improving the view of the vocal cords and allowing for successful tracheal intubation. The AIROD was also able to move copious secretions blocking the view of the glottis in a few patients including those patients receiving chest compressions. Even during blind intubation, including one time when the light on the laryngoscope failed, the AIROD provided tactile sensation to the tracheal rings known as “tracheal clicks” that helped ensure correct tracheal placement of the endotracheal tube (2).

This study is limited by its small sample size and retrospective nature, and by that fact that not all intubations were timed because of the emergent nature of some of the intubations. The inventor of the AIROD did most of the intubations and others might not achieve equal results. A prospective trial on the timing of first-pass intubation success using the AIROD would be most useful to confirm the findings in this study.

In conclusion, the AIROD first-attempt intubation success rate was found to be similar to the rate for the traditional plastic bougie. Direct inspection of the oropharynx during intubation confirmed no significant trauma occurred during intubation.

Conflicts of Interest

Evan D. Schmitz, MD is the inventor of the AIROD and was the primary operator for most of the intubations mentioned in this study. No financial assistance was provided for this study. The AIROD instruments were donated to the hospital from AIRODMedical.com.

Acknowledgments

The author thanks H. Carole Schmitz, Carol Fountain and Abra Gibson for their editorial comments.

References

1. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. [CrossRef] [PubMed]
2. Schmitz ED. Decreasing COVID-19 patient risk and improving operator safety with the AIROD during endotracheal intubation. J of Emergency Services. EMSAirway. 11/2020.
3. Schmitz ED. AIROD Case Series: A new bougie for endotracheal intubation. J Emerg Trauma Care. 2020;5(2):20. [CrossRef]
4. Schmitz ED. Single-use telescopic bougie: case series. Southwest J Pulm Crit Care. 2020;20(2):64-68. [CrossRef]
5. Schmitz ED, Park K. Emergency intubation of a critically ill patient with a difficult airway and avoidance of cricothyrotomy using the AIROD. J of Emergency Services. EMSAirway. 01/2021. [CrossRef]
6. Collins SR. Direct and indirect laryngoscopy: equipment and techniques. Respir Care. 2014 Jun;59(6):850-62; discussion 862-4. [CrossRef] [PubMed]
7. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352. [CrossRef] [PubMed]

Cite as: Schmitz ED, Park K. First-Attempt Endotracheal Intubation Success Rate Using A Telescoping Steel Bougie. Southwest J Pulm Crit Care. 2021;22(1):36-40. doi: https://doi.org/10.13175/swjpcc004-21 PDF