COVID-19 is the latest coronavirus disease that emerged in China in December 2019. An emerging infectious syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus Researchers is now aware that when an infected person coughs or sneezes the new coronavirus is transmitted by droplets released into the air.
Incubation period:
Symptoms tend to develop in humans within 14 days of exposure to the virus.
Symptoms of COVID-19
- Cough
- Fever
- Shortness of breath
- Muscle aches
- Sore throat
- Unexplained loss of taste or smell
- Diarrhea
- Headache
Anesthesiologists, CRNA’S and other perioperative care providers are at special risk as they provide respiratory support and tracheal intubation to COVID-19 patients. The anesthesia team must pay attention to the importance of adequate measures when caring for these patients with respiratory treatment and intubation.
Point to Consider Prior to Intubation:
- Personal protective equipment (PPE) with airborne precautions for all anesthesia team members at the bedside or in the OR.
- Only the disposable equipment, drugs to be used should enter the operating room.
- Protection against droplet production during extubation and recovery should be maintained.
- Rapid sequence induction for general endotracheal anesthesia (GETA).
- The choice of GETA versus LMA depends on the clinical scenario.
- Regional anesthetic techniques can be preferred if appropriate.
Personal Protective equipment’s:
All staff in the operating room or patient room who have direct contact with the patient must use the PPE, regardless of the anesthesia technique chosen. CDC recommends healthcare personnel who come in close contact with confirmed or possible patients with COVID-19 should wear the appropriate personal protective equipment such as
- gown
- gloves
- face shield
- N95 Respirator or powered air-purifying respirator (PAPR)
Anesthesia Considerations:
Airway setup: For GETA consider using one size ETT and blade for example 7.5 ETT and MAC 4 Blade, so that you can minimize the wastage. Only bring the necessary equipment to the operating room or procedure area. American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists ( AANA) recommend using a video-laryngoscope to improve intubation success and avoid awake fiberoptic intubations, when possible.
Place a HEPA filter between the breathing circuit Y-piece and the airway for the patient’s mask, endotracheal tube, or laryngeal mask. The HEPA filter should be placed on the expiratory end of the corrugated respiratory circuit before the expired gas reaches the anesthesia system for pediatric patients or other patients in which additional dead space or filter weight might be troublesome. A HEPA filter should also protect the gas sampling tubing, and gases leaving the gas analyzer should be scavenged and not permitted to return to the air in the room.
Suggested induction, maintenance and emergence drug setup:
- Induction agent: (propofol, etomidate, ketamine), midazolam, lidocaine, opioid (fentanyl, Sufentanyl), succinylcholine
- Maintenance drugs: non-depolarizing neuromuscular blockers ( Rocuronium, Vecuronium, Cisatracurium, Pancuronium), opioids ( fentanyl, sufentanil, remifentanil, Morphine, Dilaudid)
- Resuscitative drugs: ephedrine 5 mg/mL syringe, phenylephrine 100 mcg/ml, other resuscitative drugs such as epinephrine, atropine must be available
- Reversal agents (neostigmine and glycopyrrolate or sugammadex)
- Avoid the use of NSAIDS (e.g., ketorolac). March 11, 2020 letter in The Lancet Medical Journal, which hypothesized that an enzyme (a molecule that aids a biochemical reaction in the body) is increased by NSAIDs and could aggravate COVID-19 symptoms.
Laryngoscopy and intubation:
- If patient’s condition permits, denitrogenation with 100% oxygen until end-tidal oxygen is at least 80%.
- After intubation, double gloves would allow one to remove the outer gloves and reduce the subsequent environmental contamination.
- In any location where intubations occur, the intubation should be done by the most qualified specialist for that area.
- Unless explicitly indicated, avoid awake intubation with fibreoptics. During this process, droplets containing viral pathogens that become aerosolized. Aerosolization produces smaller particles of liquid which can be suspended in air currents, traverses filtration barriers, and is inspired.
- For induction and emergence, two members of the anesthesia team should be present in the OR at all times one member of the anesthesia team will remain outside the OR immediately to provide additional medications or equipment if necessary.
- If available, use a closed suction system during airway suctioning.
- After removing protective equipment, avoid touching your hair or face and perform hand hygiene.
- Use appropriate decontamination procedures for the equipment according to your institutional policy.
Emergence and Recovery:
- Identify where recovery will occur. Extubating in the operating room or ICU. IF extubating in the OR, take necessary precautions not to contaminate equipment and only necessary personnel in the room during extubation.
- If you are planning to recover the patient in ICU and the patient is transported with ETT in place, the bacterial/viral filter must remain in place between ETT and manual ventilation device
- Patients who are not ventilated should wear a surgical mask.
- The patient should be recovered in the operating room or transferred to an airborne infection isolation room.
The information given above is constantly changing please check as we learn about this novel coronavirus, Please refer CDC, AANA, ASA, APSAF for more up-to-date information.
Disclaimer: The information and materials given herein are given for information and educational purposes only and do not constitute medical or legal advice or create a standard of treatment. Readers are advised to consult with their own medical / legal experts and organizations.
Sources:
Steps Healthcare Facilities Can Take Now to Prepare for COVID-19, https://www.cdc.gov/coronavirus/2019-ncov/hcp/steps-to-prepare.html
ANESTHESIA CARE OF THE PATIENT WITH CORONAVIRUS DISEASE 2019 (COVID-19, https://www.aana.com/docs/default-source/marketing-aana-com-web-documents-(all)/2020_covid-19_infographic_v3.pdf?sfvrsn=20c9498d_6
COVID-19, Information for Health Care Professionals, https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-occupational-health/coronavirus.
FDA advises patients on the use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19.
Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?, https://www.thelancet.com/action/showPdf?pii=S2213-2600%2820%2930116-8