June 23/30, 2020 e933 Existing American Heart Association cardiopulmonary resuscitation (CPR) guidelines do not address the challenges of providing resuscitation in the setting of the coronavirus disease 2019 (COVID-19) global pandemic, wherein rescuers must continuously balance the immediate needs of the patients with their own safety. To address this gap, the American Heart Association, in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists, and with the support of the American Association of Critical Care Nurses and National Association of EMS Physicians, has compiled interim guidance to help rescuers treat individuals with cardiac arrest with suspected or confirmed COVID-19.Over the past 2 decades, there has been a steady improvement in survival after cardiac arrest occurring both inside and outside the hospital. 1 That success has relied on initiating proven resuscitation interventions such as high-quality chest compressions and defibrillation within seconds to minutes. The evolving and expanding outbreak of severe acute respiratory syndrome coronavirus 2 infections has created important challenges to such resuscitation efforts and requires potential modifications of established processes and practices. The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients. Complicating the emergency response to both out-of-hospital and in-hospital cardiac arrest is that COVID-19 is highly transmissible, particularly during resuscitation, and carries a high morbidity and mortality.Approximately 12% to 19% of COVID-positive patients require hospital admission, and 3% to 6% become critically ill. [2][3][4] Hypoxemic respiratory failure secondary to acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest, [5][6][7][8] as do some of the proposed treatments such as hydroxychloroquine and azithromycin, which can prolong the QT. 9 With infections currently growing exponentially in the United States and internationally, the percentage of patients with cardiac arrests and COVID-19 is likely to increase.Healthcare workers are already the highest-risk profession for contracting the disease. 10 This risk is compounded by worldwide shortages of personal protective equipment (PPE). Resuscitations carry added risk to healthcare workers for many reasons. First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway. During those procedures, viral particles can remain suspended in the air with a half-life of ≈1 hour and

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

More than 20 000 infants and children have a cardiac arrest per year in the United States. 1-4 In 2015, emergency medical service-documented out-of-hospital cardiac arrest (OHCA) occurred in more than 7000 infants and children. 4

These data demonstrate that mean DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old was associated with greater likelihood of survival to hospital discharge and survival with favorable neurological outcome.