Taking a Closer Look into Neurocritical Care Mechanical Ventilation During the COVID19 Pandemic and the Use of Anesthesia Machines in the Neuro ICU
By Shaun Golden, MSN, RN; and Sarah Beth Thomas, MSN, RN, CCRN, CNRN, SCRN
It is our experience in neurocritical care that tells us that the mortality and morbidity of our patients does in fact rely upon the availability of mechanical ventilation. Respiratory management and the use of protective ventilation in early phases of brain injury, such as TBI, ICH or strokes, is critical in preventing secondary hypoxia, hypotension and hypercapnia. Despite numerous clinical studies, the safest ventilatory setting has yet to be established in reducing the risk of ventilator-induced lung injury (VILI), impaired cerebral venous drainage, intracranial hypertension and increased ICP.
During an extreme resource-limited pandemic, the inability to overcome several obstacles, like equipment, infrastructure and human resources, would inhibit delivering high-quality ventilatory care. In the event of a shortage of ICU ventilators, is getting an anesthesia ventilator versus not getting a ventilator an option? Should this even be a consideration when we have anesthesia machines sitting idle in the OR? A risk-benefit assessment on the use of an anesthesia device for long-term ventilation was imperative. Weighting the risk of the off-label usage of a Dräger anesthesia device against benefit of being able to ventilate a patient in crisis is the right decision.
We utilized a true multidisciplinary approach to think outside the traditional “box,” and we successfully collaborated with our procedural colleagues from anesthesia. We changed the ventilators in the Neuro ICU over to the Drager Apollo anesthesia machine for a preemptive trial. Our decision for this trial was the use of anesthesia machines as ICU ventilators on patients who were not COVID-19 positive to reduce the risk of the rebreathing system becoming a COVID-19 vector.
This all became possible on March 22, 2020, when the FDA issued guidance outlining a policy intended to help increase availability of ventilators as well as other respiratory devices and accessories during the COVID-19 pandemic. This was policy was effective immediately.
The change to anesthesia machines in the ICU also necessitated a change in workflow. An anesthesia professional needed be immediately available at all times (24/7/365) to manage the the anesthesia machine as an ICU ventilator. Intensivists, ICU nurses and respiratory therapists are not trained to manage anesthesia machines, so CNRAs and anesthesiologists were deployed to the ICU to provide this support.
Quick to react to the pandemic, a joint committee representing the ASA, APSF, SOCCA and SCCM developed the educational program: COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU project. The industry was also quick to react, and clinicians are directed to the manufacturers' websites for specific instructions on safe use of anesthesia gas machines for this new long-term indication.
Our experience using anesthesia ventilators over a 10-day period was a very positive. The biggest concern that was identified was the increased staff, with associated cost, that is needed to safely operate the anesthesia machines in the ICU setting. From our trial, we are confident that any patient needing ventilatory support can be ventilated with anesthesia machines capable of providing controlled ventilation or assisted ventilation. While this may be outside of the traditional use of anesthetic indication, by following recommendations and guidelines of FDA, industry, professional societies and hospital policy anesthesia machines can be used in the Neuro ICU if needed during a resource shortage generated by a pandemic.#LeadingInsights