Perioperative management of coronavirus patient and critical care concerns

Nidhi Kaeley; Prakash Maha; Rohan Bhatia; Suman Choudhary

doi:10.4103/jssrp.jssrp_15_21

REVIEW ARTICLE

Year : 2021 | Volume : 2 | Issue : 3 | Page : 42-45

Perioperative management of coronavirus patient and critical care concerns

Nidhi Kaeley¹, Prakash Maha¹, Rohan Bhatia², Suman Choudhary³
¹ Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
² Department of Anaesthesia, SRHU, Dehradun, Uttarakhand, India
³ Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission	10-Jul-2021
Date of Acceptance	22-Sep-2021
Date of Web Publication	28-Dec-2021

Correspondence Address:
Prakash Maha
Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jssrp.jssrp_15_21

Abstract

Coronavirus disease 2019 caused by SARS-COV-2 virus was first detected in China in December 2019. The World Health Organization declared it as a public health emergency of international concern on January 30, 2020. It is a beta coronavirus with identical genome as that of bat coronavirus hinting to bats as a natural host. It causes a wide spectrum of clinical symptoms. They include fever, dry cough, fatigue, loss of smell, diarrhea, and severe pneumonia leading to acute respiratory distress syndrome. The elderly population and those with underlying comorbidities are more prone to severe pneumonia and higher mortality. At present, India is in the stage 2 of local transmission of SARS-COV-2 infection. However, Indian government in collaboration with the Indian Council of Medical Research is taking stringent steps to prevent stage 3 transmission that is community spread. In this review article, we discuss evidence-based principles and guidelines of infection control and perioperative management of patients in COVID-19 times. The emphasis is on the use of personal protective equipment's and hand hygiene steps to prevent viral transmission by and to the anesthetist and other frontline health-care workers as well as patients.

Keywords: Coronavirus patient, critical care, perioperative management, personal protective equipment's

How to cite this article:
Kaeley N, Maha P, Bhatia R, Choudhary S. Perioperative management of coronavirus patient and critical care concerns. J Surg Spec Rural Pract 2021;2:42-5

How to cite this URL:
Kaeley N, Maha P, Bhatia R, Choudhary S. Perioperative management of coronavirus patient and critical care concerns. J Surg Spec Rural Pract [serial online] 2021 [cited 2023 Mar 31];2:42-5. Available from: http://www.jssrp.org/text.asp?2021/2/3/42/334044

Introduction

In December 2019, the Chinese authorities identified a cluster of cases of pneumonia at Wuhan in China.^[1] It was later identified to be caused by novel coronavirus which is a positive sense RNA beta coronavirus, also termed as SARS-COV-2. It has around 79% genomic similarity with the previous coronaviruses.^[1],[2] The most common clinical symptoms include fever, dry cough, rhinitis, myalgia, loss of smell, diarrhea, and severe pneumonia progressing to acute respiratory distress syndrome. The common laboratory features include leukopenia, lymphocytopenia, raised aspartate aminotransferase, raised troponin levels, and D- dimer levels.^[3],[4] The principle route of transmission of SARS-COV-2 is through droplets and contact transmission of virus through fomites. Droplets spread by sneezing can infect up to a distance of two meters. However, aerosol-generating procedure such as endotracheal intubation, noninvasive ventilation (NIV), suctioning, high-flow nasal oxygen provision, bronchoscopy and sputum production, generate small aerosols which enter the surgical masks and pose risk to both the health-care workers and the patients.^[5] The minimum number of viral particles that can cause infection in at least 50% of human beings is called as the minimal infective dose. The minimum infective dose of SARS-COV-2 is still unknown. SARS-COV-2 has been found to have similar environmental inoculation as that of SARS-COV. The virus can be detected on surfaces for up to 72 h and remains in air for three hours after coughing.^[6]

In this review, we have discussed various aspects of intubation and perioperative management of suspected or confirmed cases of SARs-COV-2 infection. First of all, it is recommended that these patients should not be allowed to stay in the waiting rooms for long. They should be immediately shifted to negative pressure operating rooms for treatment to avoid further exposure. The patients after complete recovery in the operating room should not be allowed to wait in the recovery room. All the high-risk procedures including intubations, extubations, and tube change should be carried out in negative pressure room. It is advisable to carry out endotracheal intubation early in the negative pressure room. If the negative pressure is not adequate, a portable high-efficiency particular air filter should be applied.^[7]

Steps and Considerations during Anesthesia Process

The first step is preparation of manpower and is of par mount importance. The most experienced anesthetist team should be chosen, who is efficiently able to perform endotracheal intubations. Furthermore, anesthetist assistant team should be ready to effectively aid in all difficult procedures. The anesthetic team should be replaced every 2 h to prevent exhaustion. All the involved doctors as well as staff should done personal protective equipment's (PPE) and adequate time should be given before the surgery for the same. It is difficult to differentiate between asymptomatic positive and negative cases. Since testing each and every patient will increase the financial burden on the patient as well as the health-care system, it is advisable to conduct only emergency surgeries and defer the elective ones. All endotracheal intubation should be carried out in the negative pressure chambers. The expected negative pressure is minimum 12 air exchanges per hour.^[8]

Preanesthetic evaluation of each patient should be carried out in an isolation room donning proper PPE. PPE includes long length, full sleeves and water-resistant gown and shoe covers, N95 masks or powdered air-purifying respirators should be worn, adequately covering mouth and nose. Eye goggles as well as cap should be worn by the health-care workers involved in the surgery. They should also wear double gloves so that outer glove can be removed. The patients should wear surgical masks. After every procedure, the inner glove along with face shield, shoe cover, and gown should be disposed of in a double-zip lock plastic container. The next step is selection of intubation technique. Clearly, the patients with severe SARS-COV-2 frequently require noninvasive and invasive ventilation. Hence, while securing airway, one should defer using awake fiberoptic intubation as spraying local anesthetics can aerosolize the viruses. Video laryngoscopes should be preferred for intubation during endotracheal intubation. A high-efficiency hydrophobic filter should be applied between the face mask and the breathing circuit or between the face mask and the reservoir bag. One should always preoxygenate with 100% oxygen for 5 min. To prevent aerosolization of virus into the surroundings, rapid sequence intubation (RSI) should be considered. High-flow nasal cannula device should be avoided. All the used airway equipment including laryngoscopes should be kept in double zip locked plastic bag to further reduce contamination of the surroundings. PPE should be removed as per the protocol and hand wash should be performed post-PPE removal.^[7]

The World Health Organization (WHO) recommends the use of surgical face masks while attending any patient of suspected COVID-19. However, ECDC suggests the use of at least class 2 or 3 FFP masks in such situation.^{[9],[10],[11]} According to the UK guidelines of airway management, PPE should be worn at all times while managing airway as well as while performing procedures involving aerosolization.^[12] High-flow nasal oxygen (HFNO) delivers warm oxygen through nasal cannula at the rate of 60 l/min. It is recommended in patients with type 1 respiratory failure. Although it reduces the need of intubation, there is enhanced risk of exhaled aerosol dispersion associated with it. As observed by one of the studies, the mean dispersion distance is directly proportional to the flow of HFNO.^[13]

Hence, the WHO now recommends that the use of HFNO and NIV should be avoided.^[14] Appropriate care should be taken while transporting COVID-19 positive or suspected cases into the negative pressure operating rooms. While transportation, the patient should wear surgical masks and the health-care workers should don full PPE. To alleviate anxiety among patients, benzodiazepines or opioids should be prescribed to all the patients. The intubated patients must be shifted on bain circuit with HEPA filter attached between endotracheal tube connector and Y limb.^[14] Suctioning should be done using closed suction apparatus. Muscle relaxant should be given to prevent coughing.^[15] The anesthetist team should be ready with disposable syringes, face mask, endotracheal tube, laryngoscope blade, circuit etc. The operating room temperature should be set at around 20°C–22°C.^[14] The electrocardiography, NIBP, spo2, and Etco2 leads should be covered by plastic covers which can be discarded postuse. In case of difficult intubation, C- Mac video laryngoscope should be kept ready and fiberoptic intubation should be avoided.^[16] Antiemetics and prokinetics should be administered in every case.^[17] RSI technique should be used in every case.^[18] Maintenance of anesthesia should be done with intravenous anesthesia in place of inhalational route. Dispersible 50 ml syringes and PMO lines should be used for the same. Appropriate depth of anesthesia should be maintained to prevent bucking in between the procedure. Lung protective strategies such as optimal PEEP and plateau pressure less than 35mm of Hg should be attained to achieve spo2 >90%.^[19] In case of use of point of ultrasound, both the ultrasound machine as well as the probe should be covered with plastic sheath. All the invasive procedures should be carried out under ultrasound guidance.^[20] Postsurgery, the decision of extubation should be done in asymptomatic patient and risk of re-intubation should be kept low to avoid exposure.^[20]

Special Circumstances

Pregnancy

The presenting symptoms and signs of obstetric patients are similar as in any other patient of SARS-COV-2. These patients present with fever, dry cough, rhinitis, shortness of breath, and sometimes gastrointestinal symptoms. In a series of 147 cases of pregnant women, as described in China, around 8% patients had severe respiratory distress and only 1% required mechanical ventilation.^[21] Data on clinical outcomes of pregnant females during previous SARs and MERs epidemics is suggestive of poorer outcomes and higher rates of tracheal intubation, renal failure and disseminated intravascular coagulation.^[22],[23] It has been observed that most of the pregnant women suffering from SARS-COV-2 infection have mild symptoms. But still, the data about COVID-19 obstetric patients is grossly lacking. Liu et al. described a case series of 13 pregnant women with confirmed SARS-COV-2 infection; fever was the chief complaint in ten patients; three patients were discharged in healthy condition; ten patients had to undergo emergency cesarean section due to fetal distress or intrauterine fetal death.^[24]

At present, most of the studies disregard any risk of vertical or transplacental transmission of the virus.^[25]

PPE is recommended for all the health-care workers for both their protection and prevention of further spread of infection. Respirators which protect against both droplets and aerosols are rated as per a “filtering face piece” score. The respirators are graded into nine categories (N95, N99, N100, P95, P99, P100, R95, R99, and R100). The size of the filter depends on the percentage of aerosol of 0.3 micron in diameter filtered. The health-care workers are recommended to don N95 or FFP3, especially those who are involved in aerosol-generating procedures.^[26] There is very limited data on labor analgesia. However, a Chinese study on 99 nonpregnant females observed mild thrombocytopenia as a common hematological disorder. They also conclude that severe disease was associated with greater reduction in platelet count.^[27]

Thus, before giving epidural or spinal analgesia/anesthesia, one should check platelet count to avoid bleeding complications. Labor ventilations only require droplet transmission PPE as it is not an aerosol-generating procedure.^[28] Any suspected or positive case of COVID-19 receiving epidural anesthesia should be monitored frequently for fever as one of the known complications of epidural anesthesia is fever.^[29]

Nitrous oxide analgesia can be used in suspected or confirmed cases of SARS-COV-2. It is not an aerosol-generating procedure. However, there is a risk of contamination of the equipment circuit. Hence, appropriate filters should be used.^[30]

At present, there is no data on the use of remifentanil PCA in obstetric suspected or confirmed cases of SARS-COV-2; remifentanil has been known to cause respiratory depression. Hence, it should be used with caution, the preoperative planning of suspected or confirmed obstetric cases of COVID-19, posted for cesarean section should be done diligently.

Detailed history of respiratory complaints should be taken. The intensive visits should be alerted, especially in patient with severe SARS-COV-2 infection or ARDS. The operation theater used for all these patients should be prepared before, and the same anesthetic machine should be used for all the cases, to prevent the risk of cross infection. The use of ultrasonography for respiratory system examination and monitoring should be encouraged. Intra and postoperative case management of obstetrics patients undergoing cesarean section is on the similar lines as mentioned above.^[31]

Conclusion

In most of the hospitals, the anesthetists are the frontline warriors involved in the care of COVID-19 patients in collaboration of primary care physicians and critical care specialists. Hence, knowledge of patient safety measures is prudent for the entire team of doctors actively involved in the care. The primary physicians play an important role in imparting knowledge and form an essential link between super specialists and the patients. These steps are paramount for doctors as well as patients to control infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med (Lond) 2020;20:124-7.
2.	Wu F, Zhao S, Yu B, Chen YM, Wang W, Hu Y, et al. A new coronavirus associated with human respiratory disease in China. Nature 579, 265–269 (2020). Available from: https://doi.org/10.1038/s41586-020-2008-3.
3.	Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
4.	Nicolle L. SARS safety and science. Can J Anaesth 2003;50:983-5.
5.	Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.
6.	Loeb M, McGeer A, Henry B, Ofner M, Rose D, Hlywka T, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis 2004;10:251-5.
7.	Kim HJ, Ko JS, Kim TY. Recommendations for anesthesia in patients suspected of COVID-19 coronavirus infection. Korean J Anesthesiol 2020;73:89-91.
8.	Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA 2020;323:1610-2.
9.	World Health Organization. Rational Use of Personal Protective Equipment for Coronavirus Disease (COVID-19): Interim Guidance, 27 February 2020. Geneva: World Health Organization; 2020.
10.	Guidance O. COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0.: Department of Health and Social Care (DHSC). Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England; 2020.
11.	Adlhoch C, Cenciarelli O, Chiossi S, Handzlik M, Ndirangu M, Palm D. Guidance for Wearing and Removing Personal Protective Equipment in Healthcare Settings for the Care of Patients with Suspected or Confirmed COVID-19. Solna: ECDC; 2020.
12.	Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists. Anaesthesia 2020;75:785-99.
13.	Hui DS, Chow BK, Lo T, Tsang OT, Ko FW, Ng SS, et al. Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks. Eur Respir J 2019;53:1802339'.
14.	Durie M. NHS Guidance on use of NIV in adults with coronavirus \| INTENSIVE Review. Availabel from: https://intensiveblog.com/nhs-guidance-on-use-of-niv-in-adults-with-coronavirus-intensive-review/. [Last accessed on 2021 Jun 20].
15.	Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020;67:1-9.
16.	Peng PW, Ho PL, Hota SS. Outbreak of a new coronavirus: What anaesthetists should know. Br J Anaesth 2020;124:497-501.
17.	Cheung JC, Ho LT, Cheng JV, Cham EY, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med 2020;8:e19.
18.	Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
19.	Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Military Med Res 2020;7. Available from: https://doi.org/10.1186/s40779-020-0233-6.
20.	Madjid M, Solomon S, Vardeny O. ACC Clinical Bulletin: Cardiac Implications of Novel Wuhan Coronavirus (2019-nCoV). Available from: https://www.acc.org/latest-in-cardiology/articles/2020/02/13/12/42/acc-clinical-bulletin-focuses-on-cardiac-implications-of-coronavirus-2019-nco. [Last accessed on 2021 Jun 12].
21.	Haque M. The COVID-19 pandemic – A global public health crisis: A brief overview regarding pharmacological interventions. Pesqui Bras Odontopediatria Clín Integr 2020;20:0146.
22.	Schwartz DA, Graham AL. Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: Lessons from SARS, MERS, and other human coronavirus infections. Viruses 2020;12:194.
23.	Wong SF, Chow KM, Leung TN, Ng WF, Ng TK, Shek CC, et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol 2004;191:292-7.
24.	Liu Y, Chen H, Tang K, Guo Y. Withdrawn: Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect 2020 5:S0163-4453(20)30109-2. doi: 10.1016/j.jinf.2020.02.028. Epub ahead of print. PMID: 32145216; PMCID: PMC7133645.
25.	Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus disease 2019 (COVID-19) and pregnancy: What obstetricians need to know. Am J Obstet Gynecol 2020;222:415-26.
26.	Lee SA, Hwang DC, Li HY, Tsai CF, Chen CW, Chen JK. Particle size-selective assessment of protection of European standard FFP respirators and surgical masks against particles-tested with human subjects. J Healthc Eng 2016;2016:8572493.
27.	Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.
28.	England PH. COVID-19: Infection Prevention and Control (IPC). Available from: https://www.gov.uk/government/publications/wuhan-novel-coronavirusinfection-prevention-and-control. [Last accessed on 2020 Apr 06].
29.	Greenwell EA, Wyshak G, Ringer SA, Johnson LC, Rivkin MJ, Lieberman E. Intrapartum temperature elevation, epidural use, and adverse outcome in term infants. Pediatrics 2012;129:e447-54.
30.	Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) Infection in Pregnancy. London: Royal College of Obstetricians and Gynaecologists; 2020.
31.	Buonsenso D, Pata D, Chiaretti A. COVID-19 outbreak: Less stethoscope, more ultrasound. Lancet Respir Med 2020;8:e27.