Medical Journal of Dr. D.Y. Patil Vidyapeeth

REVIEW ARTICLE
Year
: 2021  |  Volume : 14  |  Issue : 2  |  Page : 128--133

Adaptation of anesthesia practices owing to coronavirus disease-2019 pandemic


Raunaq Chakraborty1, Anju Gupta2, Anjum Goth2, Prashant Sirohiya3, Nishkarsh Gupta1,  
1 Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
2 Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
3 Department of Anaesthesia, ABVIMS, Dr. RML Hospital, New Delhi, India

Correspondence Address:
Nishkarsh Gupta
Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, Ansari Nagar, New Delhi
India

Abstract

For coronavirus disease-2019 (COVID-19), substantial proportion of secondary transmission may occur before illness onset. During the epidemic of severe acute respiratory syndrome, it was evident that particularly those involved in airway-related procedures such as endotracheal intubation was highly susceptible. In this situation, we anesthesiologist need to rapidly keep updating ourselves with the available literature and adopt and evolve new practices in our regime. In this article, we have tried to suggest evidence-based practices for the perioperative management and operation theater workflow in the existing scenario of the coronavirus pandemic.



How to cite this article:
Chakraborty R, Gupta A, Goth A, Sirohiya P, Gupta N. Adaptation of anesthesia practices owing to coronavirus disease-2019 pandemic.Med J DY Patil Vidyapeeth 2021;14:128-133


How to cite this URL:
Chakraborty R, Gupta A, Goth A, Sirohiya P, Gupta N. Adaptation of anesthesia practices owing to coronavirus disease-2019 pandemic. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Apr 12 ];14:128-133
Available from: https://www.mjdrdypv.org/text.asp?2021/14/2/128/310708


Full Text



 Introduction



Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a ribonucleic acid virus that causes an influenza-like disease.[1] Following its emergence, in December 2019, in the Hubei (China), there was an exponential outbreak in the city of Wuhan.[2] The secondary transmission may occur before illness because its serial interval near to or even smaller than its median incubation period.[3] The contagiousness of coronavirus disease-2019 (COVID-19) is very high almost double to that of seasonal flu, its basic reproduction number (R0) value is calculated to be 2.68 (95% credible interval [CI]: 2.47–2.86).[4] As on May 29, 2020, the caseload from the disease throughout the world is 59,33,322 cases with a total number of recorded deaths as 362,629. India is yet to enter community transmission where we have around 167,441 cases, and 4797 deaths have been attributed to the disease till date.[5]

During the SARS outbreak, the world has seen that 21% of the infected individuals globally were health-care workers. A lot of experience learned from the SARS situation had helped us in the current pandemic. The prevention of infection in health-care settings encompasses all the principles of infection prevention and control. The risk of infection was much higher in health-care workers before personal protective equipment (PPE) was used. Early recognition, triage, and prompt isolation of suspected cases have to be the normal now.[6],[7] During the epidemic of SARS, it was evident that particularly those involved in airway-related procedures such as endotracheal intubation were highly susceptible.[8] From such experiences, it is evident that we need to evolve our practices to maintain our health systems rapidly.

In this situation, we anesthesiologist find ourselves in a very high-risk group of contracting the infection owing to the daily exposures we have to the aerosols-generating procedures in the operation theaters (OTs) and the intensive care units in our daily practice. There is a need to rapidly keep updating ourselves with the available literature and adopt and evolve new practices to our regime. The purpose of this article is to have a certain comparison of evidence-based practices owing to this pandemic about our day to day anesthetic practices.

 Materials and Methods



A systematic literature search was done on commonly used search engines such as PubMed and Google Scholar using the following key words: anesthesia, coronavirus, COVID-19, anesthesia practices. These references were cross-checked, and the articles containing all these keywords were thoroughly checked for including in our review.

Standard definitions

Suspect case

Acute respiratory illness (fever and at least one of the following symptoms, e.g., shortness of breath and cough), and a history of contact with a person that is from a place with community transmission during the 14 days before symptom onset;[9]

Or

Acute respiratory illness with a contact with a confirmed or probable case in the last 14 days before symptom onset;

Or

Severe acute respiratory illness (fever and at least one symptom of respiratory disease, e.g., shortness of breath, cough, and needing hospital admission) and absence of an alternative diagnosis that explains the clinical condition completely.

Contact

There are considerable variations in the definition of who is a contact. Broadly for this article, we can consider the definition of four organizations, i.e., World Health Organization (WHO), The Centers for Disease Control and Prevention (CDC), National Center for Disease Control (NCDC), and European Center for Disease prevention and Control (ECDC).[9],[10],[11],[12]

The infection primarily spreads through:

ProximityDirect physical contactHealth-care worker giving care without recommended PPECertain local risk assessments.

Proximity

The proximity or face-to-face contact has been variedly defined by the WHO (a likely or a known case within 1 meter for 15 min or more), CDC (contact within 6 feet with a known case for a prolonged period), and ECDC (contact with a confirmed case within 2 meters for 15 min or more).[9],[10],[12] NCDC classified contact as high risk contact and a low risk contact.[11] Notably, NCDC in high risk contact has considered those who were in proximity a distance of 3 feet of a confirmed case. The idea of someone being labeled as a possible suspect of COVID-19 comes from the theory of droplet spread of the infection.

Direct physical contact

All guidelines agree that direct contact with an established case constitutes a source of infection. As such any contact with infected secretions without recommended PPE also renders one as a contact.[11],[12] Anesthesiologists are particularly vulnerable to contract COVID-19 during the perioperative period.

Infection control in perioperative area

Owing to the asymptomatic spread of the virus, it is required that every patient be treated as a potential suspect and standard universal precautions be taken against all patients. Moreover, there should be escalation of our existing precautions, especially while handling airway of patients. In an early study of COVID-19, 43% patients acquired infection in the hospital setting.[13] Strict adherence and knowledge of available guidelines are required to maintain the integrity of our health systems. It was found that, due to suboptimal infection, control procedures lead to the spread of infection to 81 residents, 34 staff members, and 14 visitors in one long-term care facility in Washington, United States of America.[14] To reduce the risk of infection, all patients arriving in the health facility should be checked prior to visit, preferably over a telephone for symptoms that are consistent with COVID-19 and should wear a simple surgical mask. In addition, they must be educated about the hand hygiene practices and encouraged to incorporate them in their day to day practice.[15]

Guidance for patients

All patients entering the health facility needs to be screened prior to preferably over a telephone for symptoms that are consistent with COVID-19. Every patient must be given a simple surgical mask after entering the health facility, and frequent hand hygiene must be incorporated in practice to prevent cross infection.[15]

Guidance for visitors

Moreover, the number of visitors in the hospital should be restricted to minimum and universal use of masks and hand hygiene education should be given. In addition, a meticulous record has to be maintained to ensure contact tracing if the need arises.[15]

Guidance for health-care worker in the perioperative area

The perioperative area must have separate areas for donning and doffing with separate areas for entry of health-care workers and patients. The perioperative area must be marked as a high-risk zone owing to the number of aerosols-generating procedures that are undertaken there on day to day basis. Staff training is of vital importance to ensure correct donning and doffing methods are maintained.[15]

Personal protective equipment recommendations

The following recommendation is a summary of health-care provider recommended PPE in high-risk areas from the guidelines given by CDC, WHO, and public health England. According to the logistics of a particular set up and availability of PPE, the ideal workflow of every set up has to be determined with individual adaptations. The basic idea is protection from airborne virus particles in high-risk areas where frequent aerosol-generating procedures are frequently done by using evidence-based recommendations of masks and protection from droplet spread by using barrier methods such as gloves shoe covers, and coveralls.[16],[17],[18]

Mask: If availability is not an issue N95 or higher-level respirator must be used for all cases. Higher level respirators include powered air purifying respirators (PAPRs), or elastomeric respirators. The masks must be compliant with medical N95 respirator standards such as NIOSH N95, EN 149FFP2, or similar. The masks must have fluid resistance of minimum 80 mmHg pressure based on ASTM F1862, ISO 22609, or similar. All disposable masks must be discarded after exiting the patients' room or care areas, with hand hygiene to be done after touching the mask always. If PAPRs are being used, they should be cleaned as per the recommendations. Surgical masks may be used at other places of the hospital, especially in the non-COVID-19 areas if availability of N95 masks is an issueEye protection: disposable eye goggles must be used at all timesGlovesGowns and Coveralls: Disposable or nondisposable gowns must be used at all times in high-risk areas, i. e., areas, especially where aerosol-generating procedures are frequently done like the OTs. All disposable gowns must be disposed of carefully after exiting the specific care areas.[17],[18] The quality of the coverall must meet or exceed ISO 16603 class 3 exposure pressure, or equivalentDisposable caps and shoe covers: The proper sequence of donning and doffing of the above and especially doffing should be very thoroughly done by the concerned health-care worker. Adequate training, proper sequential sign displays, and simulations should be made available to all OR staff.

Operation theatre setup

Ideally all OTs should have negative pressure rooms to prevent viral dissemination.[16] In our current scenario, all our OTs are positive pressure OTs. Nevertheless, in such a scenario, a high frequency of air changes (around 25/h) helps to reduce the viral load rapidly.[17]

All patients requiring surgery must be considered as positive until proven otherwise to minimize the spread of infection. Clearly defined workflows and standard operating procedures must be made as per institutional policy for health-care professionals managing these patients.

All unnecessary equipment should be removed, and only bare necessities on case to case basis should be kept inside the OT only. Standard anesthetic trolleys should be modified to have minimal but adequate stock. All the materials should ideally be disposable as far as possible including linen.

The OT door must always be kept closed and have clear sign to prevent unnecessary movement. The movement to supply materials during surgery should also be dissuaded.[18] After the patient left the OT, logistics should allow enough time before the next procedure to reduce the chances of air contamination.

We would suggest that all patients be screened for COVID-19 before elective surgery to control the growing epidemic crisis and eliminate all possible cross-infection to healthcare workers and patients in the perioperative period.[16] The preoperative care of the patient is summarized in [Table 1].{Table 1}

Anesthetic management

Preoperative evaluation

The OTs are a source of infection and have the potential for an epidemic spread of the infection in the hospital set up owing to a large amount of personnel involved and resulting cross-contamination. A proper multidisciplinary approach as shown earlier involving surgeons on deciding the priority basis for surgery and a proper screening system involving infectious disease experts and anesthesiologist are required to properly screen patients.[16] A joint statement from the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation recommends that in areas of high COVID-19 prevalence, testing for COVID-19 should be performed for all patients prior to nonemergency surgery and that surgery should be delayed until the patient is no longer infectious and has recovered from COVID-19. Reverse transcription polymerase chain reaction may detect most presymptomatic patients during screening, but the window of diagnostic utility is small, if we consider the incubation period from the last date of the patient's exposure and interpret the negative results carefully. From the methods highlighted in [Table 1] and [Table 2], we have till date been able to identify some asymptomatic positive cases preoperatively.{Table 2}

Recommended PPE for health-care workers in the anesthesia preoperative evaluation clinic should include white medical gowns, medical gloves, eye protection shields, disposable surgical caps, and surgical masks or test fit N95 masks or respirators.[18]

Patients receiving an anesthesia preoperative evaluation should enter the consulting room one by one to minimize close contact with the clinician and other individuals.[18]

Patients' body temperatures should be measured (electronic ear thermometer) before entering the consulting room. If the body temperature is higher than 37.3°C, he or she must be escorted to the clinics for fever disorders immediately and should be reported to the infection control officer on duty of the hospital. Patients with normal body temperature can proceed with the evaluation at the anaesthesia clinic. Furthermore, for screening purposes, a portable pulse oximeter might be used as a number of COVID cases are asymptomatic and might present with hypoxia without any symptoms, the term happy hypoxia is being used for such patients.

During the first encounter, the anesthesiologists should take a detailed history and conduct a thorough physical examination, particularly a careful chest examination. Newer innovative measures such as the digital wireless stethoscopes might be considered for such purposes. In addition, specific history and examination to rule out COVID should be taken[17] [Table 2].

In addition, high risk surgical (tracheostomy, surgical procedures that need high speed drilling, and rigid bronchoscopy) and anesthetic procedures (awake fiber-optic intubation, mask ventilation high flow nasal cannula, and noninvasive ventilation) should be identified and technique/procedure should be modified.[17,26] Specifically, during laparoscopic procedures, an appropriate suction might be used with attached HEPA filters during desufflation of pneumoperitoneum. Desufflation during laparoscopy surgeries has shown to create plumes which might contribute to OR contamination. Avoiding high energy devices such as ultrasonic scalpels and electrical energy devices might also be a good idea in the current scenario as they are also known to create surgical plumes. Clear communication needs to be established in such procedures and adequate precautions might be taken preemptively during such procedures by reducing the operating room personnel, minimizing the procedure times. Airway management should be planned and preferably be done in minimum amount of time [Table 3].{Table 3}

 Conclusion



In the present pandemic, it is of vital importance that evidence-based recommendations and practices be followed in perioperative settings. All precautions must be taken to prevent OTs from becoming hot spots for the disease and we should ensure optimal care for patients as per evidence-based literature in the perioperative care including the postoperative neuropsychiatric symptoms that may be perceived by the patients. Adequate practice-based recommendations and their implementation must be followed among the health-care workers to protect them and to maintain the integrity of our health systems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Zheng J. SARS-CoV-2: An emerging coronavirus that causes a global threat. Int J Biol Sci 2020;16:1678-85.
2Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020;395:470-3.
3Nishiura H, Linton NM, Akhmetzhanov AR. Serial interval of novel coronavirus (COVID-19) infections. Int J Infect Dis 2020;93:284-6.
4Fauci AS, Lane HC, Redfield RR. Covid-19 Navigating the uncharted. N Engl J Med 2020;382:1268-9.
5Coronavirus Disease 2019 (COVID-19): Situation Report, 124. World Health Organization; 2020. Available from: https://apps.who.int/iris/handle/10665/332229. [Last accessed on 2020 Jun 05].
6Summary of Probable SARS cases with Onset of Illness from 1 November 2002 to 31 July 2003. World Health Organization; 2015. Available from: https://www.who.int/csr/sars/country/table 2004_04_21/en/.[Last accessed on 2020 Jun 05].
7National Laboratories. World Health Organization. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance. [Last accessed on 2020 Jun 05].
8Caputo KM, Byrick R, Chapman MG, Orser BJ, Orser BA. Intubation of SARS patients: Infection and perspectives of healthcare workers. Can J Anaesth 2006;53:122-9.
9Global Surveillance for Human Infection with Coronavirus Disease (COVID-19). World Health Organization. Available from: https://www.who.int/publications/i/item/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov). [Last accessed on 2020 Jun 05].
10HAN Archive 00429. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020. Available from: https://emergency.cdc.gov/han/2020/han00429.asp. [Last accessed on 2020 Jun 05].
11Ministry of Health & Family Welfare-Government of India. COVID_19: National Centre for Disease Control (NCDC). COVID19 India: National Centre for Disease Control (NCDC). Available from: https://ncdc.gov.in/.[Last accessed on 2020 Jun 05].
12Case Definition for Coronavirus Disease 2019 (COVID-19), as of 29 May 2020. European Centre for Disease Prevention and Control; 2020. Available from: https://www.ecdc.europa.eu/en/covid-19/surveillance/case-definition. [Last accessed on 2020 Jun 05].
13Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-1069.
14McMichael TM, Clark S, Pogosjans S, Kay M, Lewis J, Baer A, et al. COVID-19 in a long-term care facility King county, Washington, February 27-March 9, 2020. MMWR Morb Mortal Wkly Rep 2020;69:339-42.
15UpToDate. Available from: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-anesthetic-concerns- including-airway-management-and-infection-control. [Last accessed on 2020 Jun 05].
16Zhao S, Ling K, Yan H, Zhong L, Peng X, Yao S, et al. Anesthetic Management of Patients with COVID 19 Infections during Emergency Procedures. J Cardiothorac Vasc Anesth 2020;34:1125-31.
17Perioperative Management of Suspected/Confirmed Cases. Available from: https://www.wfsahq.org/components/com_virtual_library/media/1c4ec5c64b9aaacf7c47f76a61fb6edc-atow-422-01.pdf. [Last accessed on 2020 Jun 05].
18Chen X, Liu Y, Gong Y, Guo X, Zuo M, Li J, et al. Perioperative management of patients infected with the novel coronavirus: Recommendation from the joint task force of the Chinese society of anesthesiology and the Chinese association of anesthesiologists. Anesthesiology 2020;132:1307-16.
19Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020;67:568-76.
20Chen X, Shang Y, Yao S, Liu R, Liu H. Perioperative care provider's considerations in managing patients with the COVID-19 infections. Trans Perioperative Pain Med 2020;7:216-24.
21Peng PW, Wong DT, Bevan D, Gardam M. Infection control and anesthesia: lessons learned from the Toronto SARS outbreak. Can J Anaesth. 2003;50(10):989-97.
22Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: What anaesthetists should know. Br J Anaesth 2020;124:497-501.
23Cheung JC, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med 2020;8:e19.
24Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier Enclosure during Endotracheal Intubation. N Engl J Med 2020;382:1957-8.
25Clinical Management of Severe Acute Respiratory Infection when Novel Coronavirus (2019-nCoV) Infection is Suspected: Interim Guidance, 28 January 2020. World Health Organization; 1970. Available from: https://apps.who.int/iris/handle/10665/330893. [Last accessed on 2020 Jun 05].
26Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020;104:246-51.