LETTERS TO THE EDITOR
Year : 2021 | Volume
| Issue : 1 | Page : 77-79
Anesthesia practice amid the pandemic mayhem: Time for critical appraisal and reorganization
Anju Gupta1, Nishkarsh Gupta2
1 Department of Anesthesiology, Pain Medicine and Critical Care, AIIMS, Delhi, India
2 Onco-Anesthesiology and Palliative Medicine, DRBRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Dr. Nishkarsh Gupta
R. N. 139, DRBRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|Date of Submission||02-Aug-2020|
|Date of Acceptance||03-Aug-2020|
|Date of Web Publication||5-Jan-2021|
|How to cite this article:|
Gupta A, Gupta N. Anesthesia practice amid the pandemic mayhem: Time for critical appraisal and reorganization. Saudi J Anaesth 2021;15:77-9
|How to cite this URL:|
Gupta A, Gupta N. Anesthesia practice amid the pandemic mayhem: Time for critical appraisal and reorganization. Saudi J Anaesth [serial online] 2021 [cited 2021 Jan 17];15:77-9. Available from: https://www.saudija.org/text.asp?2021/15/1/77/306166
To the Editor,
We read with great interest the article by Babu et al. regarding anesthetic management of a COVID suspect case. Suspected or confirmed COVID patients pose unique challenges for the anesthetist due to its contagiousness and systemic implications of the illness. Unfortunately, this article is somewhat unclear, apparently resulting from the authors' omission of recent literature, probably due to the perils of the extensive nature of the literature on the management COVID related guidelines. We wish to highlight some concerns and finer nuances regarding the case.
First, the patient was asymptomatic and only suspected to be a COVID case based on her foreign travel that was 20 days back. The definition of a suspected case is any patient with acute respiratory illness with no other etiology fully explaining the clinical presentation, and a history of travel to or residence in a place with reported local spread of COVID19 disease during the 14 days prior to symptom onset. In most cases, the incubation period of COVID is 5–11 days and generally, patient is noninfective after 14 days.
Second, there is no mention of the COVID status of the patient. Considering the widespread pandemic, all patients for any kind of surgical procedure (except emergency lifesaving surgery) should be tested for COVID-19 using reverse transcription-polymerase chain reaction (RT-PCR) and be posted only when it is negative. Also, standard personal protective equipment (PPE) inclusive of an N-95 mask and face shield should be used for all aerosol-generating procedures (AGP) irrespective of report results. They have mentioned that PPE was worn by everyone in operating room (OR), but the type of PPE used is not mentioned. In general, the surgical procedures should be triaged and only emergency and time-sensitive surgical procedures should be allowed until this epidemic is contained. Medically necessary, time-sensitive (MeNTS) scoring system is one such prioritization tool which can be utilized to manage the precious resources efficiently and ethically in these times. Also, the COVID patients who are operated have poorer outcomes due to perioperative immunosuppression, venous thromboembolism, unmasking of severe infection, etc. The necessity of doing this case without getting the RT-PCR test has not been described and could amount to exposing the staff to an avoidable risk.
We have some concerns regarding their anesthetic management of the patient. Anesthesia management for patients in COVID setting is intricate and considering endotracheal intubation is a high-risk AGP, appropriate steps should have been taken to prevent the generation of aerosols and their spread. Two-handed bag-mask ventilation while maintaining tight seal is important but not documented in report., Several barrier devices have been described like aerosol box (26), (27) with holes and use of transparent plastic drapes (used in the present case) to cover the patients head during both intubation and extubation to reduce the exposure of the anesthesiologists. But these also increase the difficulty of airway manipulation in an already difficult situation since all the people involved in airway manipulation are encumbered by wearing full PPE. In addition, fogging due to PPE may further complicate the process of intubation.
Various guidelines have suggested the use of videolaryngoscopes (VLs), but they have not clarified which one should be preferred because they tend to increase the distance between anesthesiologist and the suspected patient., The authors mention covering the CMAC, but only the monitor of CMAC was covered and the blade and the wire were left exposed to the aerosol droplets and can be a potential source of infection to others. However, the VLs may improve the overall success rates of intubation, but they may actually increase the time to intubation and number of attempts. The authors have not mentioned regarding the need to use a stylet and whether a clamp was used till the endotracheal tube (ETT) cuff was inflated. In addition, use of an intubating aid may be difficult in the presence of a barrier device, may itself increase the generation of aerosols during its removal, and one cannot clamp the ETT as per recommendation if the stylet is used., We would suggest that a VL with disposable blade, preferably a channeled one, should be used (e.g., KingVision or Airtraq VL) to reduce the need of additional intubating aids and ensure that ETT is clamped till its cuff is inflated. In addition, an agent like lignocaine can be administered to suppress cough during extubation. Use of semiclosed or open circuits should be avoided during extubation and a closed circuit with closed suction in-situ should be used., Placing wet gauze around mouth and nose during extubation minimizes the aerosol spread in addition to the use of barrier enclosure.
The authors have mentioned that the theater air vents were closed. However, dedicated COVID negative pressure OR with minimum 12-20 air changes/h has been recommended in such cases.,, Considering the patient was a suspect, she should have been allowed to recover in the OR only to avoid the exposure of the hospital staff to the aerosols during patient transfer. After extubation, a new triple-layer mask/N-95 should be worn by the patient.
?The importance of proper doffing is well highlighted, and it is the riskiest with respect to aerosol exposure and should be done meticulously. They have rightly mentioned that it was done inside the OR, but it should be done in a sequential manner one after other while using “buddy check” to be double sure.
One must not hurry to proceed for any surgery in COVID setting and proper planning must be done prior to surgery including a negative RT-PCR report, appropriate PPE selection, use of barrier devices with a channeled VL for intubation, and proper doffing after the procedure.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Babu KC, Rajan S, Paul J, Kumar L. Anesthetic management of a COVID 19 suspected patient for mastectomy. Saudi J Anaesth 2020;14:411-2. [Full text]
Al Harbi MK, Abdulmomen A, Qurashi FA, Kattan M, Ahmad AE, Eldawlatly A. Airway management and COVID19 patient-Saudi Anesthesia Society guidelines. Saudi J Anaesth 2020;14:387-9.
Gupta A, Nath S, Trikha A. Anesthesia practice in Covid-19 era: Unprecedented problems call for extraordinary solutions. J Anaesthesiol Clin Pharmacol [Epub ahead of print] . Available from: http://www.joacp.org/preprintarticle.asp?id=29061?7
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Begley JL, Lavery KE, Nickson CP, Brewster DJ. The aerosol box for intubation in coronavirus disease 2019 patients: An in-situ simulation crossover study. Anaesthesia 2020;75:1014-21.
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Anaesthesia 2020;75:785-99.
Bajwa SJS, Sarna R, Bawa C, Mehdiratta L. Peri-operative and critical care concerns in coronavirus pandemic. Indian J Anaesth 2020;64:267-74. SJA_832_20 [Full text]
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