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GUIDELINES
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 383-386

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


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

Correspondence Address:
Prof. Abdelazeem Eldawlatly
Department of Anesthesia, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_252_20

Rights and Permissions
Date of Submission30-Mar-2020
Date of Decision04-Apr-2020
Date of Acceptance10-Apr-2020
Date of Web Publication17-Apr-2020
 

  Abstract 


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.

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 Sep 25];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.[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.[2],[3],[4]

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 Top


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. Staff:

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. Preparations:

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

1.4.2. PPE

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. PPE:

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.[5]

1.6. Logistics:

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. Monitoring:

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

1.8. Pre-oxygenation:

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:

1.10.4.1.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.


1.10.4.2.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)0.916


  • 1.10.4.3.Unanticipated Difficult Airway: tracheal tube/BB

    1.10.4.31 Failed 1st Intubation Attempt: low volume BMV

    1.10.4.32 Failed 2nd Intubation Attempt: 2nd generation LMA

    1.10.4.33 Failed 3rd Intubation Attempt: cricothyrotomy

    1.10.5.Post-intubationCare and Procedures:

    1.10.5.1 Inflate the tracheal tube cuff before starting ventilation

    1.10.5.2 Confirm tracheal intubation with capnography

    1.10.5.3 Place a naso-gastric tube after tracheal intubation

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

    1.10.5.5 Discard disposable equipment safely

    1.10.5.6 Decontaminate reusable equipment

    1.10.5.7 Doffing the outer pair layer of gloves

    1.10.5.8 Hand hygiene before and after all patient contact.

    1.10.5.9 Allow surgeons and scrub nurse to go inside the room

    1.10.6.One Lung Ventilation

    1.10.6.1 Minimize the duration of surgery and OLV

    1.10.6.2 FiO2 100%

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

    1.10.6.4 Permissive hypercapnia.

    1.10.6.5 Lung recruitmentmaneuvers if needed.

    1.10.7.Extubation Options and Procedures

    1.10.7.1 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

    1.10.7.2 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


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

    1.10.7.4 PPE conditions as in intubation should be applied

    1.10.7.5 Avoid precipitating coughing

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

    1.10.8.Postoperative Recovery and Patient Transfer

    1.10.8.1 Postoperative care should be done inside the OR

    1.10.8.2 Transferring intubated/extubated follow local regulation

    1.10.9. After Care

    1.10.9.1 Discard disposable equipment

    1.10.9.2 Decontaminate reusable

    1.10.9.3 Change breathing circuit and soda lime

    1.10.9.4 Decontaminate the ABS of the anesthesia as per manufacture instructions

    1.10.9.5 Hand hygiene before and after all patient contact

    1.10.9.6 Clean room 20 minutes after completion surgery

    1.10.9.7 Ensure meticulous doffing of PPE

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    ABC Anesthesia Management in a Patient with Suspected/Confirmed COVID-19. Available from: https://drive.google.com/file/d/1XJNQyJUUBTGYukW4G8YIrlAgIKlVI3P-/view. [Last accessed on 2020 Mar 23].  Back to cited text no. 1
        
    2.
    University of Toronto. Corona virus and safety precaution. Available from: https://www.anesthesia.utoronto.ca/news/corona virus-and-safety-precautions. [Last accessed on 2020 Mar 23].  Back to cited text no. 2
        
    3.
    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. [Last accessed on 2020 Mar 23].  Back to cited text no. 3
        
    4.
    ASA-APSF Joint Statement on Non-Urgent Care DuringCOVID-19 Outbreak. Available from: https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/asa-apsf-joint-statement-on-non-urgent-care-during-the-covid-19-outbreak. [Last accessed on 2020 Mar 23].  Back to cited text no. 4
        
    5.
    Guidance on PPE to be used by health workers. Available from: https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. [Last accessed on 2020 Mar 23].  Back to cited text no. 5
        
    6.
    Insertion depth of left-sided double-lumen endobroncheal tube: A new predictive formula. Saudi J Anesth 2019;13:227-30  Back to cited text no. 6
        




     

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