Dr. Jeffrey Burns - Update on Critical Care for the patient with COVID-19

production through our outstanding staff in the ICU. And I very much thank them for an extremely short notice coming up with an instructional talk for us on what's going on in the ICU, vis-a-vis the COVID and the status of treatment for those patients. So thank you so much. All right, good morning. This is Monica. I started and Nellis is going to advance the slides. And I just want to quickly outline our objectives. We have free bullets and we have free presenters. And this is how we're going to divide up the discussion. First, I'm going to describe the epidemiology and clinical presentation of critically ill patients with COVID-19. We're going to review the pathophysiology of critical illness and the management and therapeutic options. Sally is going to provide that. And then Nellis is going to describe changes to clinical practice and models of care related to the pandemic that we have been working on in the ICU. Next slide. There has been a plethora of publications about COVID-19 coming out of the adult literature and smattering of literature related to pediatric patients. And I'm just sharing a couple of those to set the stage. As everybody knows, the effects of coronavirus on children, so it appeared to be, first of all, less frequent and then secondly, less severe. And our experience has mimicked that experience worldwide. One of the publications early on that looked at the contribution of children to critically ill patients in both China and Italy reported low proportions of children in China about 2% and Italy 1.2% in this publication of basically review of other publications that had been reporting children. And specifically, the literature coming out of China, if you will believe me, the red oval is showing the proportion of children who were critically ill in different age groups. And you can see that that really is under 2% for all of the populations with numbers in the single digits, even in a country as populist as China. Next slide. What we have observed and hearing from our colleagues is that there is occasionally a child who does get what appears to be the traditional lung disease associated with COVID-19. And Sally is going to describe this in more detail. But with the appearance of bilateral prangable infiltrates, hypoxemia, and if CT is done, ground glass appearance by CAT scan, all things that are reported in adults and occasionally reported in children. Next slide. Dr. Burns has from mid-March been holding conference calls initially twice weekly now, once weekly, and now we're extending that a little bit further as things and new information comes in at a slower pace. But essentially it's called the PICU COVID-19 International Collaborative and consists of multiple pediatric centers from six continents who get together on Saturday evenings. Now we do not have a life and have reports from various places throughout the world as to their experience with COVID-19. Reason this is so crucial is that you can see from our most recent call last Saturday night, which involved, again, six continents, total of 58 pediatric centers. Among those 58 centers, there were only 92 patients being treated in PICU's that were self-reported by those centers. And so any one center is not having significant experience and is incredibly valuable to learn from our colleagues throughout the world. And in particular, folks that are at some of the epicenters as in New York City, where they have seen a tremendous amount of COVID in both adults and more than most of us in children. Here's some of the common risk factors that have been reported. Some of these are similar to adults. They include history of asthma and obesity. These are typically teenagers who are affected with those problems. Younger children with complex care needs, neurologic or genetic problems. And then patients with an underlying malignancy or immunodeficiency have been reported. And as with adults, there have been some atypical presentations, far less of the classic lung disease and ARDS than is observed in the adult population. But many people have reported seeing patients with new onset or a DKA in the context of known diabetes malitus with a co-incidence positive COVID-19 status. As our department knows, and our surgeons know, several patients have presented with appendicitis and also our COVID positive, whether that is true, true and unrelated, we don't know. There have been several children with mild carditis reported, including those who have required mechanical support with ECMO. And just very recently, report from the UK about children presenting with Kawasaki-like disease with immune dysregulation, inflammation, and even coronary artery aneurysms. And we're going to be talking more about that on the pico-collaborative call this coming Saturday. Katri Tipo, who is an intensiveist from Tucson, has been working with a group on an adaptive survey, essentially reporting the worldwide experience with COVID-19, as well as a lot of the information about therapies. This represents a large cross-section of the world. While over half the centers reporting are from the United States, you can see that every continent is represented. And she has been illustrating for us, essentially the percent of tick-use reporting patients with COVID-19. And it has been around, as you can see, around 0.5% on average for those patients. For those tick-use who are reporting a total of 93 tick-use are contributing data. May I apply to the fight? Another survey that was done across sectional survey of North American experience with pediatric medical care was spearheaded by Dr. Shanker-Dame, Dr. Houston, and involves a number. She recruited four tick-use of 14 had data to contribute. And what's, I think, noteworthy here is you'll notice there were no tick-use in Canada reporting any cases in what was the end of March, beginning of April, for the time period when these cases were being reported, and they were largely focused in the Northeast. Next slide. And thank you, Jennifer, for providing this preliminary data. This is under expedited review for JAMA pediatrics. But they reported this cross-sectional group of 48 patients in 14 tick-use in North America, which were, by the way, all United States pick-use, with a median age of 13 years, a very high proportion with comorbidities, 83%, presenting symptoms of respiratory failure in about three quarters, and multi-organ failure in about one quarter, a little over a third required invasive ventilation, and only two of those patients, 4% expired. The most recent CDC data, by the way, has shown reports of eight pediatric deaths total in the United States, which is certainly illustrative of what we have observed by report from our colleagues. In terms of the Boston Children's Hospital experience, this data comes from Katherine Ross, who has been participating in this North American report. The first four patients were reported in that case series that's going to be published in the other three patients, sorry, have come in since after the study closed at the beginning of April. But this is the, in our experience, a total of seven patients in ICU's. Clearly, there are many more PUI's. There have also been a number of patients who are not critically ill, who have been on the wards, and in the intermediate care program for less of your symptoms. But of these, you'll see that two of them required invasive mechanical ventilation. One was a 16-year-old with underlying tuberous scolosis on immunosuppression, and then the other was a genetically complex child who has already had a tracheostomy, but did receive mechanical ventilation. The other thing that's noteworthy about these patients is that six of the seven received some sort of immunomodulating therapy or antiviral therapy, specifically for COVID-19 in the form of remdesivir, in the form of anachinra, echolismab, or steroids. And so our experience, I think, if you look at the comorbidities, six out of the seven, had some significant comorbidity, and I think we reflect somewhat the population of children at our hospital. Only one was otherwise healthy and developed in myocarditis-like syndrome. All of these patients so far have survived. Three of them have been discharged home, and it doesn't appear as though any of them is going to have mortality related to COVID-19. Next slide. And so now we're going to transition over to Sally, who's going to talk about pathophysiology and therapy. Thank you, Monica. I'm going to focus my part of the presentation on pathophysiology, pharmacotherapy, and I see the management of severe COVID-19 disease. As Monica has noted, there really are not enough pediatric patients with severe COVID-19 disease to establish patterns to really tell you about so much of what we know comes from the adult population, and that's a lot of what I will talk about with some pediatric caveats added in. So next slide. The, I find this schematic very helpful to understand the progression of COVID disease. It was made by Dr. Sidiqi and Mara at the Brigham and published in the journal Heart and Monterransplant Equalment, and describes three stages of COVID-19 disease. Stage one is the early infection stage where the immune response to the virus is taking place. There is low-grade fever and dry cough, diarrhea, and headache. And the laboratory work is really predominantly shows lymphophenia at this stage. In stage two, patients are presenting to the hospital with increased work of breathing in stage two A, and then two B is where profound hypoxemia begins to set in. And at this stage, the patients have abnormal chest imaging, and they also, notably on the labs, will start to have transaminitis. And as the host inflammatory response increases, the patients seem to, many, some of them will move into stage three. This is really the critical illness stage, which is associated with a hyperinflammatory state. Patients who progress to this stage are in the ICU. Many of them have ARDS, and some will have septic shock and cardiac failure. And inflammatory markers like CRP, LVH, IL-6, D dimer, and ferritin are elevated. And these patients may also have increased troponin and BNP. And then the general principles of therapeutic intervention are along the bottom. And I'll talk about those more in a minute, but I think just generally speaking, the therapies that are directed at the virus may be useful along the continuum of disease, but those that are anti-inflammatory are really helpful only in the sort of high-spin and low-spin stage. And those are the underneath that would be pulled out for the majority of patients. Can I have the next slide, please? And I just added in here for some perspective, the data from the largest Chinese CDC paper that was published in GM, Aback, and February, 72,314 cases that 81% of those had mild disease, which would correlate with stage one, 14% progress to the hypoxemia or greater than 50% lung involvement, which would be like stage two. And 5% progress to the respiratory failure shock and multi-organic dysfunction. And whether those same proportions hold up in pediatrics with the lower numbers, it doesn't seem to be the case, but that's what we're talking about is really sort of the progression along the continuum of disease. Next slide, please. I want to summarize as much as I can, the pharmacotherapy for COVID-19. This is a rapidly evolving situation, as you know, even from just watching the news. And this data was taken from the PICU COVID-19 collaboration presentation that was done by doctors, Katie Chodos, and Julie Fitzgerald from Chop, along with Mari Nakamura from our institution, where Jeff asked them to take the recently published Infectious Disease Society of America Guidelines and provide advice for pediatric clinicians. As you can tell from the IDSA recommendation column in the middle, there really is a lack of strong data for any of these medications. And the IDSA really strongly pushed that any of them that were used should be used in the context of a clinical trial. And obviously we don't have the same option for clinical trials in pediatrics, because our numbers are so small. But these doctors did their best to advise us about these medications. I'd like to floor it when you've undoubtedly heard a lot about in the news, it's an anti-malarial drug that has been shown to have active activity against diverse DNA viruses, including SARS-CoV-1. And the problem with it is that it has a QTC polomia effect that can cause arrhythmias, and then particularly in combination with azithromycin, which is the macrolite antibiotic, that has not been shown to have direct effect against these viruses, and is thought to actually worsen the QTC prolonging effect. And therefore, these clinicians suggested that azithromycin not be used in combination with hydroxychloroquine, but that hydroxychloroquine could be used and selects, really critically ill patients. And then the drug coletra, which is a combination of low pentadvere and retonivere that was developed for use in HIV, has been available since a 2000, and has some anti-viral effect, but the world has kind of moved towards the use of a different antiviral drug called brimdesivir, which is noted at the bottom of the bottom table of the table, that brimdesivir is a nucleotide drug that inhibits viral RNA-dependent RNA polymerase and causes premature termination of RNA transcription. It is being studied widely in the adult population, and is available through single patient expanded access requests. This is an important point, I think, to remind me that we have to, oh, a lot of thanks to our infectious disease colleagues who have really dedicated themselves to staying on top of the literature, which is there isn't much of, and also staying in touch with their colleagues around the country to try to understanding the evolving landscape of pharmacotherapy for pediatrics. We have are consulting them very early for any COVID-19 positive patients in the units, particularly to think about the use of brimdesivir early so that the expanded access can be applied for it if that's going to be used. The next medications on the list are steroids, which steroids generally used for all COVID is really suggested against the only thing that the IDSA really suggested against using. In the pediatric population, that's also true, except that if there are other conditions for which steroids would be helpful like asthma and septic shock, these clinicians agree that they could be used for that, but in the hyperinflammatory state, they may be useful in selective critically ill patients, along with tosalismab, which is an IL-6 neutralizing drug that we have used for the site of kind activation syndrome that occurs with CAR-T cell therapy. And this may also be useful in situations where the IL-6 level is high in the hyperinflammatory state in certain patients. Convalescent plasma is something that could be used across the continuum of disease. There actually is our adult and pediatric trials getting started and we will have the ability to enroll patients at Boston Children's, which is terrific. So hopefully that will live up to its potential as well. Can I have the next slide? So I just wanted to mention also that the hyperinflammatory phenotype of COVID-19 in adults has been associated with a pro thrombotic state and the adult colleague institutions have really dedicated themselves to early and aggressive thrombopropyl axis for the COVID-19 patients. They have also anecdotally told us that pulmonary embolism seems to be a cause for some of the sudden cardiac arrest they're seeing in the population and they are, while TPA has always been part of the cardiac arrest algorithm, it's being used and thought of earlier in the sequence of events for the concern of pulmonary embolism as a cause for cardiac arrest. Next slide, please. So as far as the long path of ill physiology in COVID-19, one of our field leading experts in the management of ARDS is Dr. Luciano Gattononi, who is from Milan and therefore he and his colleagues had very early experience with a large number of critically old patients with COVID-19. And they seem to note and have published in a couple of different articles that the pulmonary disease falls into two buckets. And both of them, both buckets are marked by profound hypoxemia, but they labeled one of them type one. And this was about 70 to 80% of their ICU population and they were impressed by how compliant this lung is and that it really did not, was not recruitable with peep and, I mean, airway pressure, the way the classic ARDS is. And the other type, type two, they called, they said was actually more like classic ARDS. And you can see from the CT scan pictures that that is the case with a lot of dependent adelecticists. Interestingly, they said that the type one patients did seem to be responsive in many cases to peep, maybe not as high a peep as type two, but they were responsive to peep and also responsive to prone positioning, which we'll talk more about in a minute, which was surprising, but they thought was more likely related to the loss of hypoxic pulmonary vasoconstriction in these patients and perhaps that these therapies brought about an improvement in the Q matching. And they did note that type two might be an evolution of disease, but that some patients were presenting fairly early on with type two disease in the most severe of the patients. Can I have the next slide, please? So what about the ICU management of COVID-19 patients, our pediatric ICU colleagues that are now find themselves taking care of adult patients, tell us that the adult ICU colleagues tell them to mind the four P's, which are peep, pruning, pruning, which is use of diuretics and patients. And you can see from this snippet of the Mass General Treatment Guide for critically ill patients with COVID-19, that really the first three big blue boxes are not any different from the state of the art management of ARDS that has been the main stays of therapy for the better part of the last two decades. You will see that the next box is prone, and that's prone positioning of patients for at least 16 hours a day generally. This is considered if the PO2, PO2 ratios are less than 150 in these patients. Prone positioning you may all remember was something that was studied here at Boston Children's in a large multi-center trial that was, the PI was Martha Curley who worked here and now works down at CHOP. And that study did not show a improvement, a improved outcome with prone positioning for pediatric ARDS. And so we have not, since the end of that study, done much pruning of patients here, but in the adult world, there were some studies that showed improved outcome, and it has become a part of ARDS care in a number of institutions. Now the fact that COVID-19 really hit Northern Italy where Dr. Gannonia is a big supporter and his colleagues are big supporters of prone positioning means that many of those patients were pruned and it really has become part of nearly every algorithm that I've seen for adult ICU care of COVID-19 patients. And so we have ramped up our ability to do prone positioning here. It's been done some with the patients up on 11 South and we've done a lot of simulation around getting our ICU nurses ready to prune adult, adult-sized patients again. What about additional therapies if those things have failed paralysis and inhaled nitric oxide are both used? And then I like the sort of bottom of this where it says that if the patient is stable or improving the next box is patients. And this has to do with the fact that these innovations typically are prolonged. They're on the order of 10 to 14 days or more. And that's sometimes difficult for an intensivist to just watch someone be stable and critically ill for that long. But that's an important thing to do and if patients are worsening to consider ECMO in this, in the adult patients is being used. We know that there are four to six patients on ECMO with some of our sister institutions around town and that's generally considered an adult for patients who have the fewest comorbidities and the best likelihood of surviving ECMO and its confidential complications. What's different on this algorithm compared to the pediatric world? I would say that at the top you see a void using non-invasive ventilation. And you know from Monica's slide that we have used non-invasive ventilation, I would say we are not ruling it out, but we are focused on going ahead and intubating when patients are failing modest by-pap settings. We're not using high by-pap settings in these patients and we would intubate early. And then as far as something that's missing from this algorithm that we would normally think about for pediatric ARDS is high frequency oscillatory ventilation, that's not something that has been successful in the adult world, in just in general in ARDS care, there've been some negative trials. But in pediatrics we generally would be considering it for pediatric ARDS, but back in the SARS epidemic there was increased transmission of virus to healthcare workers associated with high frequency oscillatory ventilation. They think mostly related to the mushroom valve on the oscillator being a source of aerosol that's generated continuously throughout high by. So we have recommended against using it and that of course brings me to the next slide. We're not using the oscillator then what are we thinking about ECMO? ECMO is certainly not conjured indicated for COVID-19 and may be a useful therapy for some patients. We have just thought a lot about having earlier discussions than usual about patients' candidacy. You've seen that many of our patients have comorbidities and some of those may make ECMO conjured indicated. So we'd like to talk about that early. The one sort of difference in ECMO around the country is that there's a lot more consideration around whether ECPR is indicated. The problem ECPR as you may know is the use of ECMO for patients in cardiac arrest who for whom the PALS algorithm is failing to return risk and so we can relate to ECMO. The problem is the CPR is aerosol generating procedure and ECMO cannulations during this time take 30 to 40 minutes. So it's a 30 to 40 minute aerosolized aerosol generating procedure. Some institutions have sort of said that they will not use ECPR at all for their patients and what we have said is that the risks of the prolonged aerosol generating procedure have to be weighed against the likely outcome from ECPR. And so for generally speaking in our hands and around the country, the likelihood of a good outcome after ECPR when they cause of the cardiac arrest is profound hypoxemia is very poor. And so that may not outweigh and probably won't outweigh the risk of the transmission of the disease to everyone around during an ECPR event. However, ECPR is much more commonly and successfully used in the cardiac ICU where things like an acute arrhythmia that is a response of to medications may and ECPR that would occur during cardiac arrest in that circumstance may have a very good outcome and often does. And so we've just thought that we would weigh each case independently. And with that, I will pass the baton on Tom Nolash for the next section of the talk. Thank you, Sally. In the next few minutes, I would like to highlight some of the workflow changes, some of the models of care that we've employed and some innovations that came out of the current crisis in the COVID-19 era. The MSI-CU was an interesting area for this crisis period. In terms of activity, our bed occupancy somewhere between 60 to 80% capacity throughout the last three months, the number of patients that were left in the MSI-CU were high-acuity as routine procedures were canceled. And really a lot of routine winter illnesses coming through our ED have shut down in this era of social distancing. Hence, a higher proportion of our patients are on mechanical ventilation. We continue to have sporadic ECMO patients as many as two at a time last week. In addition to this, the burden of high number of PUI's, people who were not yet ruled out, and therefore the considerations for negative pressure rooms, PPE, and training every single person in the division and the MSI-CU for all these procedures. And finally, we continue to have a high concentration of aerosol-generating procedures, airway procedures, ventilator management, suctioning, and so many others. So this kept the MSI-CU active at a high level. In terms of personnel, we ran a full schedule with three teams as usual. In March, Dr. Vinci and Dr. Burns, the leadership at BMC PICU and here had to make the tough decision of converting the Boston Medical PICU into an adult. As was done by so many other centers. And we repatriated our faculty, absorbed them into the workflow here. And what happened as a result of regional changes where many PICUs became transformed into adult ICU, getting for COVID and non-COVID adult ICU patients. Boston Children's became the only PICU in town admitting and caring for critical patients, both COVID and non-COVID related. In addition, the process changed that suddenly led us to adopt a huge curve learning in terms of how to deal with PPE and the ever-changing recommendations best practice based on evidence as was emerging was an interesting period for us. A big shout out to our simulation colleagues. They stepped up and led both in the department institution and in the MSI CU to help the entire faculty, trainees, respiratory therapists and nurses get adept at all these procedures with the help of just in time simulation both in the simsweets as well as at the bedside. Finally, the more important piece at a higher level was the regional coordination and the worldwide coordination as you've heard earlier from Monica and Sally. Jeff instituted not just an institutional collaborative GCICU led inter-intensive care coordination but also regional pediatric ICU's and regional adult ICU coordination. In addition, you've heard about the international COVID collaboration that he runs on Saturdays with an unprecedented number of pediatric critical care providers from all over the world. All this coordination allowed a seamless knowledge transfer resource sharing in the region and contingency plans that were developed at such a fast pace and employed in a wide range of areas. These are some of the examples of development, testing, simulation and rollouts that the critical care environment participated in and led. The airway procedures with the help of anesthesia colleagues the prone positioning that Sally mentioned to try to come to terms with an emerging evidence of a possibly useful therapy. CPR, I'll show you a little bit on that. As you've heard, trying to adapt to the social distancing, the personnel protection and best practices that help modify and implement a modified CPR strategy. ECMO, as you've heard already, and ramping up and implementing our search capacity in the event that we were called upon to expand rapidly to accommodate either pediatric or adult patients. What's interesting in all this is once again the simulator program that was so essential in each of these program developments to try and bring it quickly to the bedside and make comfort levels rise. What's interesting is that each of these efforts were interdisciplinary and as you can see the ICUs, the anesthesia, surgeons, emergency room, infection control, emergency management were involved in developing some of these procedures that were modified. What was most fascinating is this was done in a very short period of time. The institution stepped up and almost every department coming together to put these modifications within the February and March period. Probably one of the most concentrated efforts in a short period of time by this institution in recent memory. One example is the emergency response, the critical care search plan that was modified. This search plan was first modified during the Boston Marathon bombing and subsequently forms a document that allows us to clearly indicate how and when we can step up both in terms of bedspace capacity resources and personnel in the event of a new crisis emerging, such as this one. The search plan has various phases of activation which are clearly articulated. The initial search response at the first hint of an event followed by phase 2 and 3 which are incrementally implemented as the requirement and the severity of the crisis increases. It allows us to identify our bed capacity both in terms of number of beds that can be adopted for intensive care management, also identifying which are negative pressure isolation rooms, allowing us to expand from 150 to 200 percent capacity if necessary, including doubling of beds and using operating rooms. This document developed in coordination with so many departments also has a tiered staffing plan for each of the ICUs which is clearly outlined in terms of deployment of the number and type of personnel as would be required with escalating crises. This is associated with the triage telephone plan for the administrative team to individually contact people to be deployed. One of the biggest challenges we faced was the aerosolized spread of the disease and the number of aerosol generating procedures that we in this institution perform. On the right is a pretty popular cartoon. It's actually a live figure from a florist and dye study where the provider with a face mask is subjected to aerosol generated by a coughing patient. As you can imagine the surgeons, the anesthetists and the critical current activists on this platform today are all exposed to this. One of the most rapidly developed and deployed interventions was related to intubation. All the ICUs, including the emergency room, as well as the operating rooms, got together and developed versions of what you see here is just an example of intubation guidelines. These are clearly outlined to form checklists and they are utilized at the bedside by teams in order to both efficiently and safely perform these aerosol generating procedures. Big shout out to our colleagues from anesthesia and their expertise both bringing just not the anesthesia expertise from our institution but also participating in international and national guidelines and bringing that expertise both to the bedside and to the simulation areas where in addition to developing these guidelines such events have spurned an amazing amount of innovation. This is just one example from our operating rooms where Joe Krovero and so many others including Jamie and Pete Coasis got together with the engineering folks to develop additional barrier protection while integrating patients. It's just one example of many innovations that were developed to protect personnel against aerosol generating procedures. The next place where we had to protect was outlined by Sally in the CPR area. Cardiopulmonary resuscitation once again is a highly aerosol generating procedure exposing a large group of people to aerosols and risk of infection. To that led by Dr. Kleinman and the resuscitation group here who quickly worked at the national level to develop the American Heart Association guidelines for adjustments to CPR algorithms in pediatrics. I've alluded to a few here in this slide. In addition to significant emphasis on both limiting the personnel and donning PPEs as it most of our other procedures there was one particular aspect which was interruption of CPR to intimate. We would not do that in routine CPRs but in the event of infectious pandemics such as this the emphasis on securing the airway with a cough 10-rotracker tube to reduce the amount of aerosol generated during this procedure was emphasized. And finally mechanical CPR devices. We've seen these devices for a while in their experimental and then in adult ICU and ERs and specifically with people bringing patients in with ambulances. COVID-19 era prompted both the American Heart Association to recommend this and prompted the leadership here in our division and the resuscitation group to quickly employ mechanical CPR devices to be used at this institution. This is the Zoll Autopulse device which is the one that was procured in record time. Monica and her group are now employing this with the help of bedside just in time simulation and training and it is now ready very soon to be deployed in real time. What you see in the figure is the Zoll Autopulse which is an adjunct device an automatic hands-free chest compression device. These are some of the controls that allow you to set the number of compressions based on whether you're doing initial compressions with manual ventilation or you have secured the tube and therefore you can then have independent cycles of both compression and mechanical ventilation. The principle is to minimize exposure of aerosols during CPR and based on adult literature they are fairly comparable in both efficiency in efficiency with manual high quality CPR. These devices used and recommended and currently specified for adult population but the technical specifications allude not to age but to chest circumference in size and therefore we will be able to deploy them for most of our teenagers. Here is just a quick illustration of how it works. So as you can see a fairly interesting advance in our CPR capabilities in some of our patients in this era. We were probably three weeks into this crisis when we started hearing about drug shortages. We heard dex metadamidine, midazlam, opiates and even muscle relaxants at critical shortages almost threatening day-to-day management in the operating rooms and ICU use. The institution put together a robust surveillance strategy led by our pharmacy colleagues as you can see Shannon Manzi leading these on a regular basis with many of the folks on this call today participating. The goal of this was to have some accuracy in not only understanding the deficiencies but modeling and projecting our status in terms as you can see in this figure here details of every single drug the stocks available and a modeled out how many days of capacity currently exist in stock for us. What this resulted in was immediate formation of task forces that alluded to these red boxes which were drugs that were critically short or were going to expire very shortly. And medication conservation became a big emphasis with the help of anesthesia colleagues. We started devising alternate strategies to be used in the absence of some of these very routine medications and some innovative ways in which avoiding wastage was implemented. For example, we've been long spoiled by the tendency to draw drugs far more than what is required in anticipation of the use and then waste them and in crisis like this people have had to step up and focus on being efficient and reducing some of the wastage and these were implemented in almost every process where drugs are drawn or particularly even during the resuscitation and interventions. There are 173, 74 folks on Zoom call right now. This is a new way of life for us. The entire institution, every department, all of us have adopted this virtual technology to try to maintain life as it was before the COVID era and try to mimic some semblance of normality. On the right, the two most common ways we've used them are meetings and teaching conferences. Meetings I've seen Zoom host one of Jeff's Saturday calls. There were 400 people from all over the world on Zoom participating live and in an interactive fashion which is fascinating to maintain that level of dialogue and workflow. Teaching conferences, both at the HMS, all of so many of you are part of leading those conferences and teaching modules but even locally for our trainees. I wanted to highlight two more recent pilot versions of how we are trying to use Zoom in the ICU. One is the virtual rounding. Peter Weinstock brought this up at one of our staff meetings and very rapidly we worked to try to develop a pilot. The virtual rounding concept allows us to maintain social distancing. It allows us to leverage technology so that a group of people can participate live in a meaningful way at patient grounds and more importantly it allows efficient data visualization which is much better for decision support. For example, in this particular actual display of rounds happening on team two last week on MSI-CU, you can see a data visualization of trends in patient care with the T3 simultaneously available for everyone to visualize and and guide decision making at rounds, laboratory parameters and power charts and extra findings that are displayed on large screens and people can join in not only from different parts of the institution to maintain social distancing within reason allowing a trainee to be at the bedside performing exams that can be visualized. The presenting team, the bedside nursing team, the attendings and consultants who can call in from outside and participate live in these rounds. This same technology can be used for another important patient safety aspect which is the just in time high risk patient hurdles and we intend to pilot this within the next one or two days. In this concept outside of daily patient rounds in the middle of the night or later in the evening when resources are limited there are patients who are high risk or are not following the usual trajectory where instantly a zoom hurdle allows people from all over the place including their homes to remotely view the clinical and data trends and allow us to get primary provider input who may have a perspective from past the operating surgeon weighing in on the procedure and what would be expected and how they would be thinking about changes in the patient care patient status. Leveraging expert opinion infectious disease persons and the chronology looking at lab friends overall much better visualization and decision support in a meaningful fashion in a short period of time. These are just some examples. Now to go into a little more serious aspect by the end of March certainly by the beginning of March and end of March what became very clear is the situation in New York and Italy suggested that our adult colleagues were experiencing sharp peaks of COVID-19 cases and despite all their efforts at conserving resources it was becoming clear that they are likely to run out of both bed spaces personnel and ventilators and such resources. Ethesis and experts in emergency management quickly realized that this required a new paradigm. The IOM Institute of Medicine in 2009 had recommended something like this at that time but it was not completed and finalized. This is known as the crisis standards of care and basically it's employed when contingency search responses fail to account for the spikes in requirement and critical resources are significantly reduced. Basically what this slide shows is the basic principles of crisis standards of care. The CSE the crisis standards allow us to focus or redirect health care to prioritize to population health rather than individual outcomes. It allows us to highlight the need to focus on certain important principles like beneficence, stewardship, equity and trust and finally at the regional level it highlights some of the strategic steps in the form of involving a crisis triage officer. This person or this group is distinct from the frontline care providers and they allow in both making and implementing triage modules for scarcity. This is no longer just an idea we are now implementing at the regional level and going forward. What happened is at the national level and more importantly at the Commonwealth of Massachusetts several such drafts existed in the past but were never approved but in the COVID-19 era the Commonwealth convened the Committee of Intensivists. We were represented from our institution by Sally Vitale and Bob Trug. This group in record time deliberated and rapidly produced one of the most complicated and challenging documents. The document was released by the governor on April 7th and a division was published on April 20th. Thankfully it's becoming clear that at this time we are unlikely to need to use it but the adult hospitals had stepped up. They heroically increased their capacity both in the ICU's and personnel and with the help of the national stock of 500 ventilators, many ventilators that were dispatched from here at Boston Children's to them along with so many of our respiratory therapists and with all these efforts at stepping up it's likely that we will not use this right now in the pediatric world. Having said that the document is ready. It is the principles are being implemented and we are ready to deploy as in when necessary. Hopefully not but if another more catastrophic crisis hits us. Some of the lessons learned we were hoping to identify here we cannot account for all but one thing that was very striking for us as I'm sure in each of your divisions and departments you've noticed is crisis forces us to examine and change practice but there were many benefits of that. We improved our efficiency decreased wastage. Our workflows are much more efficient during this crisis and these changes allowed us to have better coordination both between disciplines between divisions and departments. You heard about the regional and international collaboration that Jeff was leading and so many of the leaders across the institution. Communication has been we were challenged it has been really impressive the transfer of critical information across the world and also across the enterprise down to every single workforce personnel has been impressive and some of these changes will stay with us and help us be better even in the post-COVID era. The second thing we learned was the rapid achievement of goals. We used to spending years on drafts and documents and guidelines and processes. The COVID-19 error taught us that we can do this very fast. The concept of iterative improvements having a living document which is not the end all but rather a first step and continue to modify them over time. This was most impressively demonstrated by all the divisions and departments in this institution during this COVID era. We then learned about the importance of just in time training and simulation. You weren't already bought into the concept. This error taught us that every new process requires a thoughtful process mapping, an ability to repeatedly train and practice and simulate both in settings outside the environment or at the bedside and we're really grateful for having that kind of support at this institution. Innovations, so many of you were involved in stepping up and performing small to large incremental innovations in the way we change practice whether it is development of a new barrier processes both from surgery and anesthesia to prevent aerosol spread. There is new forms of workflows whether it is employing technology rapidly to enhance our capabilities. And finally some of this contingency planning that we've described in this session may not have been used right away or as much as we had imagined the worst case scenario but these contingency planning will help us be much more prepared for the future and it may be the near future before the next crisis strikes and we will as a result of this be much more prepared and ready to face the challenges of the coming crisis. I want to thank you on behalf of Monica and Sally, we're listening to us. This is not exhausted. We try to bring a snapshot of what's happening in our world and a big shout out and thanks to everyone in this institution especially the anesthesia surgical critical care our collaboration has never been tighter and it's just a privilege to work in this place in this environment. We take questions. Thank you. Nalash, Sally, Monica, thank you so much. This is absolutely fantastic exactly what we needed. I asked people to chat in some questions but I just had a couple of quick ones we don't have too much time. For all of you I guess Sally had mentioned the early intubation issue that seems like there's been some not necessarily very evidence-based but discussion in the adult world about being less aggressive about intubation and invasive ventilation and I'm just wondering if that crosses over at all into the pediatric ICU thinking. The other question was just about how aggressively or when do you start some of the anti-virus? Do you wait until kids are critically ill or do you start those relatively earlier? I'm just sort of wondering what are you thinking about when you begin those therapies? So thanks Joe. I think as far as the early intubation stuff is concerned my sense is that that progression in the adult world is really coming from the fact that in the era of trying to make all of the ventilators you know sort of for example in Italy where you know there's a large number of patients who need to be mechanically ventilated but not all can be but then perhaps there are bipap devices a number of patients were you know put on those devices even though perhaps they would have you know otherwise been intubated and then had success with that and so it's sort of the necessity is the mother of invention or whatever and and so that you know the story of those patients is evolving and people are understanding that that may be a successful way to manage patients and we always were kind of thinking that way because we recognize that you know non-invasive ventilation has been so successful in our hands and in a number of cases you know outside of COVID and our patient population is obviously not as severely ill and so we just you know recognize early that non-invasive and it's you know associated much decreased morbidity compared with invasive mechanical ventilation particularly in terms of the use of sedatives and paralysis and all of these things that that that that might work well for us and so but then as as the use of anti-virals I think that story is evolving over time I think you know from an ICU perspective by the time the patient has has needed to come to the ICU where probably in that you know sort of leaving the second stage and into the third stage of illness and certainly anti-virals are important I think the bigger question is the part that comes with the patient who's maybe not quite as sick and out on the ward and trying to make the decision at that time and I think that story is probably going to evolve as we decide how effective these anti-virals are once we get some information back from some of the studies that are being done now because if they're very effective then the you know benefits are probably going to outweigh the risks but otherwise for now because we don't know how efficacious they are and we do know that they have side effects they're really being I think deployed when patients are approving that they have the more severe forms of the illness and that would be those patients that are in the ICU. Sally I would add that in many such cases the decision making is evolving based on best evidence as you mentioned earlier and I think once again a plug-in for our capability to do virtual consults both for things like hey what's the ID thought on what we would deploy for strategy here and even expanding it to some of our really critical ill patients where the zoom consult for critical ill patients after surgery where you know surgeons and critical care and anesthesia come together quickly and huddle along patients and this this concept is live now and we'd be looking forward to demonstrating and doing this as of now we're really excited that this technology allows us to get simple consults but also huddle in critical time for patients who are deteriorating rapidly we'd be looking forward to doing this with surgeons right away. Last quick question just nitrogoxide role do you think it will grow or not in the management of COVID patients? I'm not sure that it will grow I think inhaled nitrogoxide has always been as we know a treatment for pulmonary hypertension and so in the severe form of the disease you know in many cases there may be some evidence of mild pulmonary hypertension and perhaps I know would help for that but we also know that I know helps but only really in our hands transiently in the severe hypoxemic respiratory failure I think that I know is in all of these cases in my mind pulled out to try to improve EQ matching how long that lasts is really the question mark and in the adult world I think when it's pulled out it's really at that stage after everything else has been done and and I think I think everyone's handling it the same way which is done as a trial if it doesn't improve oxygenation then it's then it's weaned off and turned off but but almost all of the adult protocols have I know sort of down there before you get to the point of Beckham. Thanks so much again people will wrap it up here thanks for all your good work and to everybody stay safe and take care of each other and we will continue on. Appreciate it. Thank you. Thank you.