Anesthesia management of thoracic surgery in a patient with suspected/confirmed COVID-19: Interim Saudi Anesthesia Society guidelines.

The Saudi Anesthesia Society (SAS) has developed interim guidelines on perioperative care of COVID-19 patients who undergo surgery and anesthesia.[1] Patients with "suspected/confirmed" COVID-19 might be scheduled for emergency thoracic procedures either during the acute or convalescence phases of the disease. There is a demanding need to develop the SAS recommendations on the perioperative care of thoracic surgery patients during the COVID-19 outbreak. There are no relevant publications on perioperative care of thoracic surgery in COVID-19 patients. These recommendations were developed from the previous experience of management of patients during the MERS-CoV outbreak in 2012-2013 and literature available on the general airway and anesthesia care for patients with COVID-19, SARS, MERS-CoV. Copyright:

The Saudi Anesthesia Society (SAS) has developed interim guidelines on perioperative care of COVID-19 patients who undergo surgery and anesthesia.[1] Patients with “suspected/confirmed” COVID-19 might be scheduled for emergency thoracic procedures either during the acute or convalescence phases of the disease. There is demanding need to develop the SAS recommendations on the perioperative care of thoracic surgery patients during the COVID-19 outbreak. There are no relevant publications on perioperative care of thoracic surgery in COVID-19 patients. These recommendations were developed from the previous experience of management of patients during the MERS-CoV outbreak in 2012-2013 and literature available on the general airway and anesthesia care for patients with COVID-19, SARS, MERS-CoV. Literature search for all published articles on Medline and Google was performed using keywords airway, anesthesia, thoracic surgery, lung separation, personal protective equipment, Corona, COVID-19, SARS, MERS-CoV. We identified the recent publications from different societies and groups.[234]

Objectives

The task force members have developed an advisory statement on the general regulations, organization, preparations and lung isolation/separation in different types of patients during COVID-19 outbreak. We have considered the earlier released SAS recommendations for the perioperative management for patients with suspected or confirmed COVID-19 infection, who might undergo surgery and anesthesia.[1] To the best of our best knowledge, there is no reported case of confirmed “COVID-19” who has undergone thoracic surgery yet.

Recommendations

There are potential risks for both “staff” and “patients”. The latter might be presented with SARS-CoV2 with the risks for life-threatening hypoxemia. Safety of the “staff” comes first. The Task Force has developed the following recommendations based on different case scenarios:

General Recommendations

Identify the Urgency of Thoracic Surgical Procedures:

Council between anesthetists/surgeons/intensivists/infectious disease/quality specialists should be considered to identify and individualize the urgency of the cases.

All ELECTIVE thoracic surgery SHOULD BE DEFERRED during the COVID-19 outbreak, except for cancer patients who need lung resection (metastatectomy)

During the outbreak, PPE for all none suspected patients

Emergency thoracic procedures patients with suspected/confirmed COVID-19 should be done

Operating Room Setup:

None infected patients with COVID-19: in normal OR

Suspected/Confirmed COVID-19:-ve pressure OR (>12 air changes per min)

A dedicated area for donning/doffing of PPE outside the OR

Staff:

Minimum number of the staff inside the room

The most experienced anesthesiologists in thoracic anesthesia

None infected patients with COVID-19: staff by local regulations

Surgery for the Suspected/Confirmed infected patients with COVID-19: Two expert anesthesiologists/anesthesia technologist/nurse/circulating, scrub nurses/surgeons inside the OR.

Excluding staff vulnerable to infection (Geriatric, immunosuppressed, hypertensive, pregnancy, diabetic, asthma, etc.)

Preparations:

Equipment and medicines for Anaesthesia and Surgery should be prepared outside the OR room

PPE

Medicines: ketamine, etomidate, propofol, rocuronium, suxamethonium, narcotics, vasopressors, inotropes, resuscitative medicines, and neostigmine/Sugammadex.

Airway Devices: disposable blades VL/C-MAC, tracheal tubes, face masks, disposable Mapleson C (Waters) breathing circuit, Guedel airways, gum elastic bougie, airway exchange catheter, stylets, LMA, lubricant, and capnography sampling line (2 pcs),

Lung Separation/Isolation Devices: a single-use FOB size 3.8 mm, DLT (left size 35, 37 Fr), CPAP bag, BB (Univent tube, Arndt blocker, EZ blocker.

PPE:

Avoid aerosol-generating procedure (AGP), including HFNO2, NIV, FOB; open suction system, and tracheal suction.

Surgery for the none infected patients during the COVID-19 Outbreak: consider using (a) surgical mask, (b) goggles or face shield, (c) gown, (d) double gloving and (e) shoes cover.

Surgery for the suspected infected patients with COVID-19: consider using (a) head cover or hood (b) fitted N99N95 mask, (c) goggles or face shield, (d) disposable long sleeve fluid-resistant gown, (d) double gloving and (e) shoes cover.

Surgery for the confirmed infected patients with COVID-19: consider using (a) helmet (b) fitted N99)/N95 mask, (c) face shield, (d) goggles, (e) disposable long sleeve fluid-resistant gown or protective suit, (d) double gloving and (e) shoes cover. Follow donning and doffing guidelines.[5]

Logistics:

Everyone should know the plan before entering the OR

Plan ahead how to communicate clearly

Use reliable techniques that work according to local practices

Identify the need for lung separation or isolation, if really needed

Monitoring:

Routine monitors as per ASA standard (art line/CVP if indicated)

Pre-oxygenation:

HEPA filter

Place an HEPA filter on every oxygenation interface at all times.

VIRUS BLOCKADE is achieved by HEPA, not by regular filters

Pre-oxygenation Options.

Pre-oxygenation with a well-fitting mask and a Mapleson C ('Waters') or anesthetic circuit, for 3-5 min.

CPAP/PSV 10 cmH2O + PEEP 5 cmH2O, Fi.

NASAL cannula 1-3 L/min, FiO, for Apneic oxygenation to prevent desaturation.

Induction and maintenance of anesthesia:

Rapid sequence induction SHOULD BE CONSIDERED.

Drug choice propofol/etomidate/rocuronium/suxamethonium)

Maintenance left to the anesthesiologist.

Vasopressor for managing hypotension.

Ensure zero TOF before tracheal intubation.

Tracheal Intubation/Lung Separation or Isolation:

Surgeons/nurses should wait outside the room until starting ventilation and discard the equipment used for tracheal intubation.

Minimize airway manipulations.

Protective measures ( PPE, HEPA filter connected to every interface including tracheal tube or DLT, no high flow).

Lung separation/isolation options:

Intubated/SARS-CoV2/moderate symptoms of COVID-19/anticipated DA/need for postop ventilation:

Use a VL for tracheal intubation/BB

Place BB through the tracheal tube using FOB.

Awake intubation: deep sedation without topicalization.

Patient with no or mild symptoms of COVID-19.

Use a VL for tracheal intubation using either (a) a tracheal tube size with BB or (b) DLT size 35 Fr for female and size 37 F for male patients.

Use FOB to confirm the proper BB/DLT position

You can use this formula for the insertion depth of DLT measured from the mouth corner

The formula was published[6] and now under validation process with encouraging results. Using the formula will minimize using FOB and hence less Aerosolization.

DLT insertion depth formula = 0.249× (BH)

Unanticipated Difficult Airway: tracheal tube/BB

Failed 1st Intubation Attempt: low volume BMV

Failed 2nd Intubation Attempt: 2nd generation LMA

Failed 3rd Intubation Attempt: cricothyrotomy

Post-intubationCare and Procedures:

Inflate the tracheal tube cuff before starting ventilation

Confirm tracheal intubation with capnography

Place a naso-gastric tube after tracheal intubation

Avoid unnecessary circuit disconnections, Consider ETT clamping and swift the ventilator to a “standby”

Discard disposable equipment safely

Decontaminate reusable equipment

Doffing the outer pair layer of gloves

Hand hygiene before and after all patient contact.

Allow surgeons and scrub nurse to go inside the room

One Lung Ventilation

Minimize the duration of surgery and OLV

FiO2100%

Protective ventilation (e.g., Vt 6-7 ml/kg, titrate PEEP)

Permissive hypercapnia.

Lung recruitmentmaneuvers if needed.

Extubation Options and Procedures

Patient who are already intubated or those with SARS-CoV2, moderate symptoms of COVID-19, anticipated or unanticipated airway difficulty or need for postoperative ventilatory or hemodynamic support. DO NOT EXTUBATE

Patient with no or mild symptoms of COVID-19. CONSIDER EXTUBATION INSIDE THE OR

If the standard criteria for extubation met

If shortage in ICU bed and/or ventilators

Avoid post-extubation procedures (e.g. NIV, HFNO)

PPE conditions as in intubation should be applied

Avoid precipitating coughing

Place a simple oxygen face mask with N95 or surgical mask below it.

Postoperative Recovery and Patient Transfer

Postoperative care should be done inside the OR

Transferring intubated/extubated follow local regulation

After Care

Discard disposable equipment

Decontaminate reusable

Change breathing circuit and soda lime

Decontaminate the ABS of the anesthesia as per manufacture instructions

Hand hygiene before and after all patient contact

Clean room 20 minutes after completion surgery

Ensure meticulous doffing of PPE

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.