An unexpected COVID-19 diagnosis during emergency surgery in a neonate.

A 4-day-old, 3.3 kg infant presented with suspected intestinal malrotation, necessitating emergent diagnostic laparoscopy. Intra-operatively, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) came back positive. This is the first case report of emergency surgery and anesthesia in a positive SARS-CoV-2 newborn. This report highlights a neonate with an incidental positive SARS-CoV-2 test, no known exposure history, negative polymerase chain reaction maternal testing, and absence of respiratory symptoms who required modified pressure control ventilation settings to adequately ventilate with the high-efficiency particulate air filter in situ.

This case highlights the need for increased access to SARS‐CoV‐2 testing universal testing protocols the use of PPE for aerosol‐generating procedures and increased ventilatory vigilance and clinical correlation in neonates where HEPA filters are added to the circuit.

We recommend following infection control precautions utilizing PPE and following the recommendations from the Society of Pediatric Anesthesia consensus guidelines until novel preventative or prophylactic measures are available against SARS‐CoV‐2 during the COVID‐19 pandemic even with a low index of suspicion

INTRODUCTION

Coronavirus 19 (COVID‐19) infection can be transmitted to neonates from birth. , Healthcare workers in the U.S. are working with critical limitations in personal protective equipment (PPE) and testing resources. Airway management for COVID‐19 poses challenges in neonatal patients and has added risk to the provider inherent in those aerosol‐generating procedures. Recognition of ventilatory failings and good clinical judgment is important in determining the appropriate ventilator settings in neonates. We described a case of a neonate with low pretest probability for COVID‐19 infection born in a high‐prevalence region, found unexpectedly to have COVID‐19 infection during surgery.

CASE

A 4‐day‐old, 3.3 kg infant presented with suspected intestinal malrotation, necessitating emergent diagnostic laparoscopy. The child was born at 37 4/7 weeks gestation via vaginal delivery, to a 24‐year‐old G2P2 Hispanic mother with no prenatal care. The mother's SARS‐CoV‐2 screening test was negative. The infant was formula and breastfed, roomed‐in with her mother, and was discharged home at 48 hours of life. On the 3rd day of life, the infant visited the pediatrician and was otherwise at home, without sick contacts. The mother denied recent contact with infected individuals and denied any symptoms of COVID‐19.

Due to the infant's young age, maternal negative testing at delivery, and no known COVID exposures during pregnancy or after birth, the infant was not categorized as a “person‐under‐investigation” (PUI) for COVID‐19 according to institutional policy. SARS‐CoV‐2 testing (Biofire® Filmarray® Respiratory Panel) from a nasopharyngeal specimen was performed as part of presurgical screening. We proceeded emergently to the OR with pending SARS‐CoV‐2 results and made a clinical decision to utilize airborne precautions perioperatively.

The anesthesia staff donned N95 masks, googles, gowns, and gloves prior to anesthesia induction. A high‐efficiency particulate air (HEPA) filter (303; Vyaire) was placed in line between the patient and the anesthesia machine on the expiratory limb. After preoxygenation and intravenous induction, the patient was easily intubated under direct laryngoscopy with a cuffed endotracheal tube size 3.0. There was no significant air leak. We were able to adequately hand ventilate the patient and achieve normal tidal volumes and CO2 readings with HEPA filter in situ. The patient was placed on pressure control ventilation (PCV; inspiratory pressure of 17 mmHg, positive end expiratory pressure of 5, on a fraction of inspired oxygen of 50%). These ventilator settings were inadequate, and titration to higher inspiratory pressures was required for adequate endtidal carbon dioxide (ETCO2) and chest rise. The surgery was converted to laparotomy after initial laparoscopic evaluation showed complex duodenal atresia.

Intra‐operatively, the SARS‐CoV‐2 test resulted positive. At surgery end, the infant was left intubated for transport to the neonatal intensive care unit. The infant was extubated on postoperative day 1, and her postsurgical course was uneventful. Neither the neonate nor the mother showed signs of COVID‐19 illness. The patient and her mother were discharged home. On telephone follow‐up, no one in the immediate exposure group showed signs of SARS‐CoV‐2 infection. Institutional Review Board approval and HIPAA authorization was obtained.

DISCUSSION

This patient, with a low index of suspicion for COVID‐19, required emergent surgery with a pending SARS‐CoV‐2. Our institution classifies patients as PUIs if they present with COVID‐19‐like illness as described by the Center for Disease Control (CDC) or had known close exposures within the past 14 days. We perform COVID‐19 testing on all admitted patients. The test turn‐around time may be up to 36 hours, leaving providers to make clinical decisions on PPE and appropriate precautions. Although in this case we used the appropriate PPE, we do not utilize the same airborne precautions for patients at our institution that have negative COVID‐19 presurgical screening or are not classified PUIs. However, this case highlights the importance of regional prevalence of COVID‐19 infection, and that age should not be an exclusionary factor in determining PUI status.

We attributed the high ventilatory requirements to the use of the HEPA filter. The addition of monitors (ie, ETCO2) or filters will have a greater impact on the circuit resistance in a neonate compared to older children and adults. The HEPA filter has a dead space volume of 30 ml. With the HEPA filter in place, higher exhalation times are needed, which means shorter inspiratory times and potentially lower tidal volumes. In a neonate, higher inspiratory pressures are then required to compensate for these changes. Since we could not remove the HEPA filter because the baby was now COVID‐19‐positive and the first incision performed, we required higher inspiratory pressures to improve tidal volumes.

We identified this issue with the HEPA filter in situ with PUI under 10 kg. In those other instances, increasing either the tidal volume in volume control mode (VCV), or pressures in PCV, and increasing fresh gas flow, improved ventilation with HEPA filters in situ. There are many hospitals where neonatal HEPA filters might not be readily available and having this knowledge might be key to safely ventilate a small child with HEPA filters of any size in situ.

The Biofire Filmarray® Respiratory Panel utilized for COVID‐19 testing in this case was approved by the FDA for use under an Emergency Use Authorization. Each kit includes reagents for positive and negative controls. Although the test is run under a closed system with specific guidelines to avoid errors, there is a minimal risk of false‐positive results either with positive control reagent contamination or if samples are not handled properly. Such unlikely events can only be confirmed with repeat testing. The mother's test cannot be ruled out as a false negative result, which may occur when the concentration of the virus in the sample is below the limit of detection. It is also possible that the infant had a false‐positive test. Neither the infant nor her mother had repeat SARS‐CoV‐2 testing (neither PCR nor serology) after hospitalization due to lack of parental resources.

CONFLICT OF INTEREST

None.

AUTHOR CONTRIBUTIONS

Ingrid Moreno‐Duarte: Pediatric Anesthesiology Fellow; This author helped with literature review, manuscript writing and preparation. Amanda Evans: Pediatric Infectious Disease Attending; This author helped with literature review, manuscript writing and preparation. Adam Alder; Pediatric Surgical Attending; This author helped with literature review; manuscript editing. Madeline C. Vernon; Anesthesiology resident; This author helped with literature review and manuscript preparation and editing. Peter Szmuk, Pediatric Anesthesia Attending; This author helped with manuscript preparation and editing. Sarah Rebstock: Pediatric Anesthesiology Attending; This author helped with the literature review, completed manuscript writing and preparation.