Year : 2020 | Volume
| Issue : 3 | Page : 383-386
Anesthesia management of thoracic surgery in a patient with suspected/confirmed COVID-19: Interim Saudi Anesthesia Society guidelines
Abdelazeem Eldawlatly1, Mohamed R El Tahan2, Ahmed Abdulmomen1, Maan Kattan3, Abdulaziz E Ahmad1
1 Department of Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Cardiothoracic Anaesthesia, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
3 Department of Anesthesiology, King Abdulaziz Medical City, Jeddah, Saudi Arabia
Prof. Abdelazeem Eldawlatly
Department of Anesthesia, College of Medicine, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
|Date of Submission||30-Mar-2020|
|Date of Decision||04-Apr-2020|
|Date of Acceptance||10-Apr-2020|
|Date of Web Publication||17-Apr-2020|
The Saudi Anesthesia Society (SAS) has developed interim guidelines on perioperative care of COVID-19 patients who undergo surgery and anesthesia. 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.
Keywords: Anesthesia; COVID-19; thoracic surgery
|How to cite this article:|
Eldawlatly A, El Tahan MR, Abdulmomen A, Kattan M, Ahmad AE. Anesthesia management of thoracic surgery in a patient with suspected/confirmed COVID-19: Interim Saudi Anesthesia Society guidelines. Saudi J Anaesth 2020;14:383-6
|How to cite this URL:|
Eldawlatly A, El Tahan MR, Abdulmomen A, Kattan M, Ahmad AE. Anesthesia management of thoracic surgery in a patient with suspected/confirmed COVID-19: Interim Saudi Anesthesia Society guidelines. Saudi J Anaesth [serial online] 2020 [cited 2020 Jul 12];14:383-6. Available from: http://www.saudija.org/text.asp?2020/14/3/383/282791
The Saudi Anesthesia Society (SAS) has developed interim guidelines on perioperative care of COVID-19 patients who undergo surgery and anesthesia. 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.,,
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. 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:
1. General Recommendations
1.1. 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.
1.1.1. All ELECTIVE thoracic surgery SHOULD BE DEFERRED during the COVID-19 outbreak, except for cancer patients who need lung resection (metastatectomy)
1.1.2. During the outbreak, PPE for all none suspected patients
1.1.3. Emergency thoracic procedures patients with suspected/confirmed COVID-19 should be done
1.2. Operating Room Setup:
1.2.1. None infected patients with COVID-19: in normal OR
1.2.2. Suspected/Confirmed COVID-19:-ve pressure OR (>12 air changes per min)
1.2.3. A dedicated area for donning/doffing of PPE outside the OR
1.3.1. Minimum number of the staff inside the room
1.3.2. The most experienced anesthesiologists in thoracic anesthesia
1.3.3. None infected patients with COVID-19: staff by local regulations
1.3.4. Surgery for the Suspected/Confirmed infected patients with COVID-19: Two expert anesthesiologists/anesthesia technologist/nurse/circulating, scrub nurses/surgeons inside the OR.
1.3.5. Excluding staff vulnerable to infection (Geriatric, immunosuppressed, hypertensive, pregnancy, diabetic, asthma, etc.)
1.4.1. Equipment and medicines for Anaesthesia and Surgery should be prepared outside the OR room
1.4.3. Medicines: ketamine, etomidate, propofol, rocuronium, suxamethonium, narcotics, vasopressors, inotropes, resuscitative medicines, and neostigmine/Sugammadex.
1.4.4. 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),
1.4.5. 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.
1.5.1. Avoid aerosol-generating procedure (AGP), including HFNO2, NIV, FOB; open suction system, and tracheal suction.
1.5.2. 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.
1.5.3. 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.
1.5.4. 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.
1.6.1. Everyone should know the plan before entering the OR
1.6.2. Plan ahead how to communicate clearly
1.6.3. Use reliable techniques that work according to local practices
1.6.4. Identify the need for lung separation or isolation, if really needed
1.7.1. Routine monitors as per ASA standard (art line/CVP if indicated)
1.8.1. HEPA filter
- Place an HEPA filter on every oxygenation interface at all times.
- VIRUS BLOCKADE is achieved by HEPA, not by regular filters
1.8.2. 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, FiO2 =100%.
- NASAL cannula 1-3 L/min, FiO2 =100%, for Apneic oxygenation to prevent desaturation.
1.9. Induction and maintenance of anesthesia:
1.9.1. Rapid sequence induction SHOULD BE CONSIDERED.
1.9.2. Drug choice propofol/etomidate/rocuronium/suxamethonium)
1.9.3. Maintenance left to the anesthesiologist.
1.9.4. Vasopressor for managing hypotension.
1.9.5. Ensure zero TOF before tracheal intubation.
1.10.Tracheal Intubation/Lung Separation or Isolation:
1.10.1. Surgeons/nurses should wait outside the room until starting ventilation and discard the equipment used for tracheal intubation.
1.10.2. Minimize airway manipulations.
1.10.3. Protective measures ( PPE, HEPA filter connected to every interface including tracheal tube or DLT, no high flow).
1.10.4. Lung separation/isolation options:
126.96.36.199.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.
188.8.131.52.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 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)0.916
184.108.40.206.Unanticipated Difficult Airway: tracheal tube/BB
220.127.116.11 Failed 1st Intubation Attempt: low volume BMV
18.104.22.168 Failed 2nd Intubation Attempt: 2nd generation LMA
22.214.171.124 Failed 3rd Intubation Attempt: cricothyrotomy
1.10.5.Post-intubationCare and Procedures:
126.96.36.199 Inflate the tracheal tube cuff before starting ventilation
188.8.131.52 Confirm tracheal intubation with capnography
184.108.40.206 Place a naso-gastric tube after tracheal intubation
220.127.116.11 Avoid unnecessary circuit disconnections, Consider ETT clamping and swift the ventilator to a “standby”
18.104.22.168 Discard disposable equipment safely
22.214.171.124 Decontaminate reusable equipment
126.96.36.199 Doffing the outer pair layer of gloves
188.8.131.52 Hand hygiene before and after all patient contact.
184.108.40.206 Allow surgeons and scrub nurse to go inside the room
1.10.6.One Lung Ventilation
220.127.116.11 Minimize the duration of surgery and OLV
18.104.22.168 FiO2 100%
22.214.171.124 Protective ventilation(e.g., Vt 6-7 ml/kg, titrate PEEP)
126.96.36.199 Permissive hypercapnia.
188.8.131.52 Lung recruitmentmaneuvers if needed.
1.10.7.Extubation Options and Procedures
184.108.40.206 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
220.127.116.11 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
18.104.22.168 Avoid post-extubation procedures (e.g. NIV, HFNO)
22.214.171.124 PPE conditions as in intubation should be applied
126.96.36.199 Avoid precipitating coughing
188.8.131.52 Place a simple oxygen face mask with N95 or surgical mask below it.
1.10.8.Postoperative Recovery and Patient Transfer
184.108.40.206 Postoperative care should be done inside the OR
220.127.116.11 Transferring intubated/extubated follow local regulation
1.10.9. After Care
18.104.22.168 Discard disposable equipment
22.214.171.124 Decontaminate reusable
126.96.36.199 Change breathing circuit and soda lime
188.8.131.52 Decontaminate the ABS of the anesthesia as per manufacture instructions
184.108.40.206 Hand hygiene before and after all patient contact
220.127.116.11 Clean room 20 minutes after completion surgery
18.104.22.168 Ensure meticulous doffing of PPE
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with confirmed 2019 novel corona virus (2019-nCoV) or persons under investigation for 2019-nCoV in healthcare settings. Available from: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html
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Insertion depth of left-sided double-lumen endobroncheal tube: A new predictive formula. Saudi J Anesth 2019;13:227-30