Many procedures requiring sedation in the pediatric emergency department are performed by consultants from outside the department. This team usually includes orthopedic surgeons and general surgeons. As sedation is now a standard of care in such cases, we evaluated consultants' views on sedation.
To evaluate consultants' views on sedation.
A questionnaire with both open-ended questions and Likert-type scores was distributed to all orthopedic surgeons and general surgeons performing procedures during the study period. The questionnaire was presented at three medical centers.
The questionnaire was completed by 31 orthopedic surgeons and 16 general surgeons. Although the vast majority (93–100%) considered sedation important, a high percentage (64–75%) would still perform such procedures without sedation if not readily available.
Sedation is very important for patients and although consultants understand its importance, the emergency department staff must be vigilant in both being available and not allowing procedures to "escape" the use of sedation.
The first SARS-CoV-2 cases in Israel were 6 Israeli citizens who were on board the "Diamond Princess" cruise ship.
Among the 15 Israeli passengers on the Diamond Princess who were infected with SARS-CoV-2, these 6 were tested positive for SARS-CoV-2 by real time PCR (RT-PCR) of the SARS-CoV-2 Envelope (E) genes well as nasopharyngeal and oropharyngeal swabs. Four of the patients were diagnosed while on board the ship and two additional were diagnosed upon their arrival to Israel.
They were quarantined for 14 days in a designated quarantine facility at the Sheba Medical Center and followed to determine whether they developed COVID-19 disease during hospitalization in Israel. During hospitalization, RT-PCR tests were performed every three to four days.
The first 3 patients who were diagnosed in Japan, only one presented with low grade fever, while the other two were asymptomatic and 2 out of the 3 patients were treated with oral quinolones. All 3 patients had a chest CT which presented with pathological changes and 2 of them were tested later for SARS-CoV-2 IgG and found to be positive.
Patient 4 was tested negative by RT-PCR upon arrival to Israel, however he was later tested positive for SARS-CoV-2 and had a single episode of a headache which was relieved with acetaminophen. Prior to discharge a CT scan demonstrated pathological changes which are typical for SARS-CoV-2. The medical history of patient 5, included asthma. Her hospitalization lasted 27 days and she had various transient physical complaints including an event of a-typical chest pain and a single complaint of a minor productive cough. The results of her SARS-CoV-2 RT-PCR tests fluctuated, at first the viral load gradually decreased, but from day 17 in consecutive tests, varying viral loads were detected. Finally, she had two consecutive negative tests. Early nasal and throat swabs samples produced viable viral culture.
Patient 6 was found to be positive in Japan and was hospitalized, during his hospitalization he had a single episode of low-grade fever and his chest CT demonstrated pathological changes. He was discharged after 2 consecutive negative tests, however a PCR test upon his return to Israel was positive and he was admitted to the quarantine department for a total of six days, during which he was totally asymptomatic. He was discharged after two negative tests. Later he was tested positive for SARS-CoV-2 IgG antibodies.
At the beginning of the pandemic most efforts focused on severe presentation of SARS-CoV-2, while the authors focused on understanding the presentation in pauci\a-symptomatic patients. Evidence of the presence of asymptomatic SARS-CoV-2 infections has accumulated, and it is now known that the proportion of asymptomatic patients is not negligible[2, 3].
This work shows that while most of the patients did not suffer from any symptoms they still exhibit pathological changes in their CT scans as has been reported in COVID-19 patients. Furthermore, they play a role in infection transmission, which is supported by one viable viral culture from an asymptomatic patient. The authors also tried to understand the meaning of viral shedding dynamics.
There is a lot of data about viral shedding and we have a better understanding of the viral shedding kinetics then we had when this work was published, reinforcing the significance of the data that was collected in this work.
These observations add to accumulating data on the potential role of asymptomatic patients in transmission of SARS-CoV-2 and the dissemination of the COVID-19 pandemic and the resultant benefit of large-scale test trace and isolate programs in the prevention of disease spread.
1. Goldenfeld M, Nir-Paz R, Segal G, Bar-On E, Mendelson E, Mandelboim M, et al. Characteristics of Clinically Asymptomatic Patients with SARS-CoV-2 Infections, Case Series. Prehospital and Disaster Medicine. 2020;36(1):125-8. doi: 10.1017/S1049023X20001466.
2. Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020;63(5):706-11. doi: 10.1007/s11427-020-1661-4.
3. Tabata S, Imai K, Kawano S, Ikeda M, Kodama T, Miyoshi K, et al. Clinical characteristics of COVID-19 in 104 people with SARS-CoV-2 infection on the Diamond Princess cruise ship: a retrospective analysis. The Lancet Infectious Diseases. 2020. doi: https://doi.org/10.1016/S1473-3099(20)30482-5.
4. Simpson S, Kay FU, Abbara S, Bhalla S, Chung JH, Chung M, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA. Radiology: Cardiothoracic Imaging. 2020;2(2):e200152. doi: 10.1148/ryct.2020200152.
This article is a summary of previously published case report by Goldenfeld et al, at Prehospital and Disaster Medicine journal, "Characteristics of Clinically Asymptomatic Patients with SARS-CoV-2 Infections, Case Series".