key: cord-276676-lgt0rzob
authors: Moka, Eleni; Paladini, Antonella; Rekatsina, Martina; Urits, Ivan; Viswanath, Omar; Kaye, Alan D.; Yeam, Cheng Teng; Varrassi, Giustino
title: Best Practice in Cardiac Anesthesia during the COVID-19 Pandemic: Practical Recommendations
date: 2020-07-03
journal: Best Pract Res Clin Anaesthesiol
DOI: 10.1016/j.bpa.2020.06.008
sha: 
doc_id: 276676
cord_uid: lgt0rzob

The COVID-19 outbreak has influenced the entire health care system, including cardiac surgery. In this review, the authors reveal practical aspects that are important during the COVID-19 pandemic with regards to the safe delivery of cardiac anesthesia. Timing for operations of the cardio-vascular system may be well programmed, in most cases. Hence, the level of priorities must be defined for any single patient. The postponement of surgery may be convenient for most cases, if it is made in the best interest of the patient. The preanesthetic evaluation should keep attention to the respiratory history of the patient. Cardiac anesthesia is always implying some respiratory monitoring; hence the existing clinical situation of the patient’s respiratory system should be clear. In case of emergency surgery, the patient should be treated as if they potentially have or are at risk for the virus. In the case of a COVID-19 confirmed or suspected patient, attention must be made to preserve operating room and team integrity. The machineries are to be draped with plastic, in order to simplify the disinfection after the operation. Perioperative management of suspected or confirmed COVID-19 patients must strictly follow the most relevant international guidelines. This review article has synthesized the common aspect present in the most important of these.

The outbreak of the novel coronavirus and coronavirus disease was labelled as a Public Health Emergency of International Concern, in January 2020 [1, 2] . In March 2020, the rapid and exponential increase in confirmed cases of infection and number of deaths globally obliged WHO to raise the alarm and declare COVID-19 a pandemic, triggering upscaling of emergency response mechanisms worldwide. COVID-19 control has been extremely critical and demanding, having unfolded serious challenges to disease prevention and public health protection [3, 4] . Although common clinical manifestations are mostly respiratory, some patients may develop severe cardiovascular damage and are consequently at higher mortality risk [5] .

Patients with suspected or confirmed COVID-19 infection, who undergo cardiac surgery procedures, represent numerous challenges for the cardiac anesthesia team. They necessitate an extremely careful approach during perioperative anesthetic care and may reflect higher risks of perioperative morbidity and mortality. It is emphasized that management of the infected COVID-19 cardiovascular patients, as well as self-protection of involved personnel, are extremely challenging and of equal importance, mandating a meticulous handling in the perioperative setting [6, 7] .

Cardiac surgery and related anesthesia practice might not be in the frontline of COVID-19 patients' care, but coronavirus expansion resulted in an important impact in this surgical and anesthesia subspecialty. Indeed, the pandemic has already affected cardiac surgery units in multiple ways: limited number of available ICU beds and ventilation sites, necessity to postpone or cancel elective and/or complex cardiac interventional procedures, patients developing COVID-19 post cardiac surgery, coronavirus patients necessitating urgent cardiac operations, cardiac anesthetists' in-hospital transfer to staff and support ICUs in front of the pandemic, infected health care providers with consequent shortage of medical and nursing practitioners, restrictions in clinical meetings, and cancelation of training and continuing medical education [6, 8] .

Cardiac anesthesiologists have the responsibility to ensure that evidence-based anesthetic care, and only essential cardiac operations are provided to the general public. In this context, the wider burden of such procedures on the healthcare systems and health care workers needs to be minimized in the current coronavirus pandemic, by delaying elective cases, to sustain health care services [6, 8, 9] . Based on the current understanding of COVID-19 pathophysiology and the clinical characteristics of cardiovascular surgical patients, in this review, the authors highlight related anesthesia concerns and provide practical recommendations in reference to perioperative planning and management of patients undergoing cardiac surgery, along with a focus on disease control and prevention in the times of COVID-19 outbreak.

While a conclusion to proceed with or postpone a cardiovascular operation seemed easy in the low and medium escalation phase, continued escalation related to restricted ICU capacity made such decision very difficult [6, 8] ; e.g. it is difficult to answer critical dilemmas such as offering surgery only to younger, or lower risk patients. Cardiovascular surgical patients are usually characterized by a relatively progressive disease. The necessity for surgery for a given disease condition must be identified by an experienced surgeon, who will prioritize patients underlying problems and will recognize potential risks encountered delaying the operation, also taking into consideration the risks for health care providers. As such, moving on with a decision to postpone or perform a cardiac operation is not at all easy. Indeed, it can be tricky and needs to be taken after careful evaluation of patient status and health care system capacity, rather than being exclusively based on COVID-19 associated risks. In all cases, availability of medical staff (e.g., cardiac surgeon, cardiac anesthetist, ICU bed, perfusionist), potential need for isolated ICU bed, equipment (e.g., ventilators, pumps, extracorporeal membrane oxygenation, intra-aortic balloon pump, trans-esophageal echo), medical supplies, blood and blood products, should be balanced and taken into account prior to a definite conclusion. Importantly, when such decisions are taken, both the decision process and the decision making should be well documented, for obvious medicolegal reasons [9 -11] .

A knowledgeable decision-making process is emphasized and has to be based on a classification of planned interventions or/and operations in Levels of Priority (LoP), such as (a) elective (LoP I), (b) urgent (LoP II), (c) emergency (LoP III), and (d) salvage (LoP IV), as per international guidelines. In a progressively escalating situation, as it has happened in most European countries, routine elective cardiac surgery (LoP I) should be postponed as much as possible. On the contrary, operations at LoP II-IV, should be further evaluated on an individual basis, by the whole cardiac surgery team, keeping in mind that PCI or endovascular interventions are preferable and should be selected if applicable. On the contrary, in-house urgent cases (LoP II), at risk for adverse cardiac events if going home instead of remaining hospitalized, might still undergo cardiac surgery at this time point, with the application of all precautions and protective measures, as per recent recommendations. The same rule applies for LoP III & IV interventions [6, 8, 10 -12] . However, one must seriously consider such patients exposure risk to a possible COVID-19 infection, during hospitalization, and/or exposure of health care workers to patients with potential coronavirus infection. Most COVID-19 patients have mild or no symptoms and therefore, it might be difficult to identify them from the pool of in-hospital urgent cases.

Moreover, patients with acute coronary syndrome in case of severe coronary artery disease (e.g.

severe LM trunk stenosis, severe triple vessel disease with high SYNTAX score), who are not eligible candidates for conservative or interventional treatment may be operated on. This may be true also for younger patients with symptomatic severe aortic valve stenosis, left-sided endocarditis with a severe valve defect and/or large mobile vegetation, large ascending aortic aneurysm (>6 cm in diameter), and symptomatic severe mitral valve insufficiency. If the pandemic escalates into a crisis, characterized by an absolute shortage of ICU beds and ventilation sites, cardiac procedures will need to be extremely limited to absolutely essential emergency surgeries, for example acute type A aortic dissection, acute heart failure due to severe coronary artery or valvular heart disease, and ventricular septal defect. Under these circumstances, even such decisions obviously remain tough to be resolved, should be taken after examining available hospital resources and reserves, and must always be supported by an ethical and legal framework [8, 11, 12] .

In all cases, postponing elective cardiac surgery does not necessarily translate into a delay in or a neglection of patient care. It is fully understandable, as well as a realistic assumption that cardiac surgery units are responsible for their patients' best outcome, but also equally responsible towards the health care workers and the wider health care service in a region or country. Therefore, in an escalating pandemic, patients normally scheduled for elective cardiac procedures are best managed by delaying their care until a few weeks or even months later. This is probably in the patients' best interest, to avoid their exposure to the hospital environment, and to eliminate chances of an incidental COVID-19 development in their postoperative course. It is already documented that ACS patients, infected by coronavirus usually end up with a poor prognosis. Therefore, developing COVID-19 post cardiac surgery might be associated with higher mortality rates. However, cardiac patients, whose operations are postponed, should be regularly re -evaluated and strictly followed -up, before their underlying conditions evolve further, and they arrive at a point of needing a cardiac surgery of LoP II or higher. Finally, the cardiac surgery team should not only take decisions on postponing elective operations but should also discuss and plan regarding the timing of surgery in the future, based on the rapidly evolving COVID-19 circumstances, and the continuously evolving regulations and restrictions [11] [12] [13] [14] [15] .

The coronavirus is highly contagious. Its incubation period fluctuates between 4 and 6 days, although its latency period can extend up to 14 days. Most infected patients usually present with mild, flu-like symptoms, including low fever, dry cough and fatigue, or can be even asymptomatic. The mean age of a COVID-19 case is reported to be 49 years. Worse outcomes are associated with geriatric populations and those with underlying diseases, such as obesity, cardiovascular comorbidities, pulmonary disorders, and/or diabetes. Di erential diagnosis can appear extremely challenging, since common influenza is characterized by similar signs and symptoms. Chest radiography or thoracic CT scan may be utilized, in identifying evidence of secondary pneumonia [4, 5, 14] .

Taking into consideration that invasive or at least minimally invasive cardiorespiratory monitoring is usually required in most cardiac surgery procedures, all patients proceeding to OR must be treated as confirmed COVID-19 cases, not only if the disease is suspected, but until a test result becomes available. Additionally, in an escalating pandemic, candidates for elective or semi-elective cardiac operations may be best managed by delaying their care until a few weeks or even months later, or in the worst case postponed until COVID-19 virus detection results are negative, at least twice, with a minimum of 24 hours between tests [6] [7] [8] [9] 13] . It is known that patients with acute coronary syndrome, who are infected with coronavirus, often have a poorer prognosis compared to the general population. Therefore, developing COVID-19 after cardiac surgery might contribute to a complicated postoperative course and be associated with higher morbidity and mortality rates [15, 16] .

In the event of an emergency cardiac surgery operation, COVID-19 status mandates immediate evaluation, in terms of patient recent epidemiologic and respiratory infection history, clinical manifestations, and laboratory and radiographic testing, including but not limited to temperature, respiratory pathogen testing, serum IgG level, complete blood count, CRP and procalcitonin levels, SARS-CoV-2 nucleic acid testing, and chest CT scanning. In case enough time is not available for a complete preoperative evaluation prior to surgery, preoperative hospitalization and preparation must strictly follow the already published guidelines for suspected/confirmed COVID-19 cases. Such patients should be admitted to an airborne isolation room (single room with negative pressure and frequent air exchange), with the quarantine necessity being evaluated and finally decided, according to SARS-CoV-2 nucleic acid testing and chest CT scanning examination results [17] .

A multidisciplinary team consisting of cardiac surgeons, cardiac anesthesiologists, respiratory infectious disease experts, perfusionists, and nursing staff should be involved in coordinating such patients care. For healthcare personnel involved in suspected or confirmed coronavirus cases, level 3 infection control precautions (such as disposable hat, medical masks [N95 or above], powered air purifying respirators [PAPR], scrubs, disposable gloves, and disposable shoe covers) should be strictly applied throughout the whole perioperative period. Personnel clinical observation and follow-up for signs and symptoms of COVID-19 must not be forgotten and should be carried out closely after their clinical involvement in such patients care. In case of health care personnel exposure risks, an isolation period of at least 14 days is mandatory [6] [7] [8] 12] .

Keeping in mind the ease of in-hospital coronavirus contaminating capability and expansion, and that all health care workers are among those at high risk of infection, they must all routinely apply protective and preventive measures, with attention to details, to avoid any nosocomial spread to patients and healthcare nursing and medical personnel. Indeed, precautions in the care of all patients and in the interaction between health care personnel are of paramount importance, to limit infection spread, as much as possible.

It is highly recommended that all health care providers focus on their personal protective equipment. In this context, all should wear a N95 mask, surgical cap, gown, protective eye googles, shoe covers, double gloves, and PAPRs or protective full-face shield, during very contact with suspected or confirmed COVID-19 cardiac surgery candidates [6] [7] [8] . A dedicated operating room for the suspected/confirmed cardiac surgery COVID-19 patients must be readily available and in absolute isolation from the rest of operating theatres, with a warning sign posted outside and with predefined, dedicated preoperative and postoperative patient transportation pathways, which must be disinfected regularly. COVID-19 OR set up, workflow and organization are extremely critical. Surgical devices and anesthetic equipment must be unique and dedicated only to the predefined COVID-19 OR, without any chance of being transferred to other operating sites. All non-essential surgical and anesthetic equipment needs to be removed outside this dedicated OR. The operating room should also be converted to a negative pressure environment with airflow changes, with doors remaining shut at all times, to maintain an optimal negative pressure at all time points of the cardiac patient perioperative care [6, 7, [17] [18] [19] .

Coordination of and collaboration between healthcare practitioners, workflow of the COVID-19 OR (inclusive of, but not restrictive to routine universal infection prevention practices, donning and doffing personal protective equipment [PPE] , and decontamination after the procedures), and designated personnel must be planned on a daily basis, also evaluated and adapted to circumstances dynamic alterations. Cardiac surgery is a complex operative procedure that cannot be completed successfully without a group of health care practitioners. Such operations must involve a dedicated team, limited to the minimum number of nursing and medical personnel (cardiac surgeon, anesthesiologist, anesthesia nurse/technician, CPB technician, perfusionist, scrub and circulating nurse). All team members should be assigned and allocated to their roles prior to COVID-19 patient entrance in the OR. Irrelevant staff should not enter the COVID-19 OR to minimize unnecessary traffic. Staff management can take appropriate measures to separate workers/anesthetists/surgeons into groups, so that possible necessary quarantines can be applied to groups within each unit, rather than the unit as a whole, which could lead to the closure of the entire cardiac surgery service, something that is especially true for smaller cardiac surgery units [6-9, 13, 19] .

All equipment and devices required, for endotracheal intubation, arterial and central venous cannulation, syringes, gauzes, surgical drapes, surgical instruments, sutures, material for cannulation prior to cardiopulmonary bypass (CPB), oxygenator and circuit for CPB, prosthetic grafts and valves must be checked for adequacy prior to surgery and be set and positioned properly and definitely prior to patients arrival in the OR. The aim is to have as minimal as possible traffic in circulation across the COVID -19 OR. Additionally, high-touch surfaces of devices like anesthesia machines/workstation, infusion pumps, CPB machine, cell-saver device, IABP, heat exchangers and computerized devices for documentation should be wrapped with plastic sheets, to facilitate cleaning and decontamination after the end of surgery and following patients transportation to ICU, as per international general guidelines. Strict measures and precautions for infection control should be implanted and must definitely be applied in the case of suspected/ confirmed COVID-19 cardiac surgery patients [6] [7] [8] [9] .

First, in reference to staffing management, and based on the potential complexity of a cardiac operation, two experienced cardiac anesthesiologists and a cardiac anesthesia nurse are necessary to be present inside the cardiac surgery OR, directly being responsible for the patient anesthetic care. A third cardiac anesthesiologist should be readily available outside the OR, serving as backup and consultant, in case it becomes necessary [6, 9] .

OR traffic should be limited to the minimum. Only dedicated staff should be allocated for specimen collection and delivery (e.g. arterial blood samples analysis, ACT, thromboelastography, blood tests etc.). All healthcare providers involved should be covered by level III protection and should wear in the following order: N95 mask, disposable surgical cap, disposable work uniform, disposable medical protective uniform, scrub, gown, anti-fog goggles, shoe covers, first layer disposable latex gloves, isolation gown, and full-face respiratory devices or powered air-purifying respirator (PAPR), if available. Anesthesiologists must wear gloves before contacting the patient and eventually patient body fluids, such as blood, urine, mucus, or other potentially contaminated objects. In such case, vigilance is required to remove the outer gloves, followed by appropriate hand hygiene, with gloves repositioning being strongly advised afterwards. Extreme care should be applied to avoid touching surfaces prior to contaminated gloves removal. Also, contaminated, semi-contaminated, and clean zones should be clearly defined, and protective equipment must be removed consequently, and when necessary, according to the hospital guidelines and protocols [6, 8, 13, 17, 19] .

A specific note must be given to surgeons and scrub nurses preparation in terms of personal protection. They should put the surgical mask and cap above PPE, then get scrubbed in and move on with putting on the surgical coat with double gloves. Gloves should be long-sleeve and fixed to sterile coat with adhesive tape or drapes.

Regarding equipment and devices preparation, anesthesia machines, monitors, TOE probes, US machines, blood gas analyzers, ACT machines, and disposable OR supplies must be prepared well in advance. The Waste Anesthetic Gas Disposal system should be checked for proper working provisionally and must be equipped with the necessary filtering and sterilizing functionalities. The Centralized Waste Anesthetic Gas Disposal system should be avoided, to prevent the spread of coronavirus among operating rooms, in case standard negative pressure in the OR cannot be achieved. An independent (preferentially portable) negative pressure suction device should be readily available in each OR. A video laryngoscope (disposable laryngoscopes whenever possible) is strongly recommended and advised to be utilized, if available, to improve the success rate of endotracheal intubation, thus reducing exposure time. Video laryngoscope must also be used even in case of unplanned emergency circumstances for securing airway [6-8, 17, 18] .

Cardiac surgery patients must always wear a N95/surgical mask, and at all times, and should be transported to the OR through a predesigned pathway. Nasal oxygen supply /therapy can be offered underneath the surgical mask when needed. A Venturi mask is advised to be avoided [7, 17] . In patients with severe cardiac and pulmonary dysfunction, intra-aortic balloon pump, or extracorporeal membrane oxygenation (ECMO) might be considered [6-8, 19, 20] .

General rules and principles: Current guidelines 1. All non-essential or unnecessary equipment and devices must be kept outside the COVID-19 OR, during anesthesia induction and endotracheal intubation (ETI). All anesthesia induction and resuscitation equipment must be prepared and ready for use, prior to patient transfer in the OR.

Anesthesia and intubation protocols for COVID-19 cases must be strictly followed [6 -8, 18, 21 ].

2. Arterial and CV catheterization are recommended to be facilitated by ultrasound guidance, to improve success rates, reduce procedural times, and avoid multiple vessel punctures, that could contaminate surrounding personnel via blood [6, 7, 17, 22] . 3 . In general, regional anesthesia is preferred to GA in surgical procedures. However, in most cardiac surgery circumstances, a single RA technique cannot be applicable, although it may be combined to GA, based on the type of surgery, as an adjunct to a GA technique, for adequate perioperative pain management [6, 23, 24] 10. Electrostatic heat and moisture exchange filters (HMEF) must always be used in the anesthesia circuit throughout the intubation process, as its virus filtration efficiency reaches 99.9995%. For suspected patients, lower respiratory tract secretions should be collected through the ETT, and specimens should be sent for examination as soon as possible [25] [26] [27] [28] .

patients COVID-19 patients may suffer from severe viral myocardial damage. Elevated cardiac injury biomarkers are commonly found in COVID-19 patients. Among other manifestations, hypertension, heart failure (with a high incidence in elderly), hypoxia-induced myocardial damage (especially after myocardial infarction, unstable angina, or in patients with a PCI history), and stunned myocardium have been reported. Multiple explanations have been described, all related with a high expression of ACE2 receptors in the heart, blood vessels, and lungs, possibly being responsible for the virus induced activation of the RAAS system. Patients receiving ACE inhibitors prior to surgery might be in higher risk for complications and worse outcome [5, [14] [15] [16] 29] .

In reference to cardiovascular monitoring, that is necessary in the COVID-19 cardiac surgery patients, minimally or advanced invasive hemodynamic monitoring (PiCCO, FloTrac, pulmonary artery catheterization) and TOE are mostly recommended to guide fluid therapy and inotropic/vasoactive drugs usage. Patients with acute MI might need IABP insertion, ventricular assist device, or ECMO mechanical circulatory support, and these devices should be applied with extreme caution to avoid transmission of infection. Intraoperative TOE is the routine technique of choice for LV function monitoring, volume status optimization, and valvular diseases evaluation, and may serve as a useful guide during cardiac anesthetic management. Concise and comprehensive TOE examination represents the primary modality for the evaluation of every cardiac disease and of a COVID-19 induced cardiac dysfunction. RV dysfunction, can be a manifestation of COVID-19 cases, after CPB, related to increased pulmonary vascular resistance and pulmonary edema, LV dysfunction, and related stress cardiomyopathy [6] [7] [8] .

Patients with SARS, under mechanical ventilatory support, suffer a higher risk for developing pneumothorax, which contributes to increased mortality rates in this subgroup of patients. As such, it is recommended that pneumothorax is excluded by CT scanning during preoperative patient evaluation. A protective mechanical ventilation strategy must be applied in all suspected and confirmed cardiac surgery cases. Pneumothorax should be suspected according to patient clinical picture (mostly decreased SpO2 or sudden blood pressure decreases. Lung ultrasound, as a basic part of POCUS, can be useful for fast evaluation and diagnosis, and a chest tube should be placed if a pneumothorax is the final diagnosis. Lung re-expansion should be verified prior to chest closure. Lung ultrasound can also be useful in assessing the severity of pulmonary manifestations due to COVID-19, by easily identifying presence of B-lines, air bronchogram, and pleural effusion, thus helping in selecting proper lung protective ventilating strategies [5, 14, 30] .

Critically ill COVID-19 patients have a high incidence of acute kidney injury and severe acidbase imbalances, with electrolyte abnormalities commonly being encountered. Continuous renal replacement therapy should be performed perioperatively when indicated. Goal -directed fluid therapy is recommended to optimize fluid administration [5] [6] [7] [8] 31] .

Blood conservation strategies should be applied, as such patients' coagulation profile is usually not normal. Coagulation status should be checked routinely via measurements of platelet counts/ function, prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), and thrombo-elastography. Antifibrinolytics, preoperative hemodilution, autologous platelet-rich plasma technology, mild hypothermia or normothermia during CPB, and intraoperative blood salvage must be used, as in non-COVID cases, to minimize blood transfusion requirements and transfusion-related acute lung injury. Coagulation factor concentrates are preferred over blood products when possible to reduce potential TRALI, which can worsen the already existing lung manifestations related to COVID-19 [6 -8] .

Major surgery and anesthesia produce well documented inflammatory and immune response in humans. In cardiac surgery procedures, extracorporeal circulation and CPB are further considered as an additional risk factor and the most important trigger for a massive perioperative inflammatory reaction, a problem that has been largely addressed in the past, because of its detrimental consequences and impact on perioperative morbidity and mortality.

Continuous blood exposure to non-endothelial surfaces (perfusion circuit) is responsible for a cascade of systemic inflammatory response, via activation of coagulation pathways, complement system, and production of tissue factor and cytokines, that can eventually result in ARDS, potentially being further complicated by blood transfusion, finally causing TRALI.

The inflammatory response during cardiac surgery occurs due to not only CPB, but also surgical trauma, anesthesia, cardioplegia and myocardial ischemia, cardiac manipulation, heparin, and protamine. Inflammatory response to CPB can be controlled and minimized by off-pump cardiac surgery, temperature maintenance and arrangement (32°-34°C for operations requiring up to 2 h of CPB), heparin coated-perfusion circuits, modified ultrafiltration, complement inhibitors, and glucocorticoids [32, 33] .

Current COVID-19 therapies are mainly supportive. Development of novel therapies and effective prevention are an urgent need, particularly for life-threatening severe acute ARDS and hyper-inflammatory syndrome (characterized by a fulminant and fatal hypercytokinemia with multi-organ failure). Several cytokines are involved in the disease pathogenesis. Likewise, some of these cytokines induce increased vascular permeability and leakage, pulmonary edema, air exchange dysfunction, ARDS, acute cardiac injury, and multi-organ failure. Novel therapies such as interleukin (IL) antagonists (dupilumab), JAK2 inhibitor (fetratinib), interferon blockers and stem cell and mesenchymal cell therapies have been applied to neutralize cytokine storm and offered some improvement. In the cardiac surgery setting, extracorporeal circulation and cellsaver application might reduce the systemic cytokine load, could in part eliminate immune and inflammatory response, and as such, might be reasonable options as alternatives and might be considered for COVID-19 patients during cardiac surgery [6 -8, 13, 20, 34] .

At the end of each cardiac operation, specific attention must be given to patient transportation, medical waste management, OR and equipment disinfection and patient and health care personnel follow up.

A single dose of an antiemetic (e.g. 5-hydroxytryptamine receptor antagonist) should be administered to prevent postoperative nausea and vomiting (a common adverse effect due to high opioid doses that are provided intraoperatively), which may be responsible for an extensive coronavirus spread. Prior to departure from OR, all healthcare providers should take off the outer layer of their personal protective equipment, in the sequence guided by local hospital policy and international guidelines. The transportation of COVID-19 patients should be performed by a personnel with PPE. This team should wear new personal protective equipment in the clean zone.

In cases undergoing cardiovascular surgery, extubation should be planned in the OR if possible and for the appropriate patients. Patients to be admitted to the ICU should be transferred in accordance with the infection prevention measures for COVID-19. If the patient transported to ICU is intubated, ventilation can be performed by a disposable AMBU bag, or an HMEFequipped portable ventilator should be used. The positive pressure ventilation should be stopped prior to disconnection from ventilator, while placing the patient to AMBU bag or the portable ventilator. If the transported patient is extubated, a N95/should be applied to patient. Regarding transportation, a pre-specified pathway must be followed, to transfer the patient to an airborne isolation intensive care unit room, specifically dedicated to COVID-19 cases. Personal protective equipment can be taken out only after leaving the isolation area.

All disposable equipment and medical waste (breathing tubes, infusion tubing, disposable laryngoscopes, sutures, drapes etc.) should be discarded. These must be put in and sealed with double-layered medical waste bags and must be treated as highly contagious medical waste.

Anesthesia machine and their surfaces, other surfaces, equipment used in OR, floor and operating table need to disinfect and decontaminate as per dictated procedures. It is advised they are wiped with 75% alcohol or chlorine-containing disinfectants. The inner circuit of the anesthesia machine should be removed and disinfected with 75% alcohol or hydrogen peroxide.

Mixed O 3 and H 2 O 2 atomized gases or pasteurization can also be applied. OR negative pressure must be maintained for at least 30 minutes, after patient departure and transfer to ICU. OR ceiling filters of exhaust vent and OR wall return vent must be definitely replaced. No operation should start in this OR before OR space has been thoroughly disinfected, as per the description provided above. Plasma air purifiers can be used for air sterilization. Alternatively, ultraviolet light can be used as well for one hour. The casing and monitor of ultrasound machines should be wiped with 75% alcohol. Quaternary ammonium disinfectants should be avoided as they can damage the casing. However, ultrasound probes can be disinfected with quaternary ammonium or hydrogen peroxide. For disinfection of the TOE probe, blood gas analyzer, and ACT machines, one should address to the manufacturer's instructions. Reusable surgical instruments must be transferred to the nearest washstand (with a COVID-19 warning sign above it) and decontaminated by personnel wearing PPE. Reusable instruments disinfection via soaking must be carried out with a chlorine containing disinfectant for at least 30 minutes [6, 8, 11, 13, 17, 19] .

Postoperative care and intensive follow-up of COVID-19 patients, necessitate establishment of a dedicated multidimensional cardiac COVID-19 team, with a particular expertise in cardiac ICU, mainly including, anesthesiologist, cardiovascular surgeons, respiratory medicine physicians, infectious diseases specialists, experienced nurses, physiotherapists, and social worker. Team decisions should be taken jointly, as a multidisciplinary decision making among the COVID-19 team can minimize specialty bias and prevent self-referral from interfering with the optimal patient care. In this context and to minimize/prevent infection, healthcare workers should follow the infection control policies and procedures already in place at their healthcare institutions. For the healthcare workers performing aerosol-generating procedures in patients with COVID19 in the ICU, it is advisable to use fitted respirator masks (i.e., N95 respirators, FFP2, or equivalent), in addition to other PPE (i.e., gloves, gown, and eye protection, such as safety goggles) as described in the infection prevention measures for COVID-19. If possible, the shift of healthcare workers should be reduced to four hours. Additionally, it is preferentially recommended that performing aerosolgenerating, nonaerosol-generating procedures in ICU patients with COVID-19 should be carried out in a negative-pressure room and a portable high-efficiency particulate air filter should be used in the room, if available. In patients who require endotracheal re-intubation, intubation should be performed by the healthcare worker who is the most experienced with airway management to minimize the number of attempts and risk for transmission and using videoguided laryngoscopy over direct laryngoscopy, if available. During ICU follow-up of COVID-19 patients, patients should be closely monitored for ARDS, systemic inflammatory response syndrome, and cytokine release syndrome. The preventive and treatment options (including antiviral treatment strategy which is subject to change) related to the diseases itself and subsequent serious clinical conditions (i.e., ARDS or shock) should be taken in accordance with the guideline recommendations [6, 8, 13, 19, 35, 36] .

Finally, one other big problem is the feeling of fear of health care providers to be diseased or contagious for their families. Therefore, they may need enormous support against burn-out during the COVID-19 pandemic.

Cardiac anesthesia provision presents with many challenges in the coronavirus era, as presented in Table 1 . For the performance of cardiac operations in the COVID-19 pandemic, it is important that a dedicated team decides on which cases to postpone for a later stage, based on an assessment of level of priority. The basic goal is to support the healthcare facilities and to protect patients from severe postoperative complications that contribute to high mortality rates, and health care workers from a potential contamination.

The rest of operations that cannot be deferred should be performed with great caution, strictly following guidelines and health authorities' recommendations, that are readily available.

Personal protective equipment is the most crucial measure during pandemic, even if in this kind of working environment is challenging. Support of health care cardiac anesthesia and surgery team is mandatory, taking into account that patients can only be treated if health care workers are healthy.

The authors have no conflicts of interest to disclose.

No funding was received for the completion of this manuscript. 

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RA preferable when applicable, combined with GA avoidance of aerosol generating processes (airway manipulation, face mask ventilation, suction awake ETI -rapid sequence induction -video laryngoscope utilization -avoidance of circuit disconnection • Cardiovascular Considerations: hemodynamic monitoring, TOE use, attention to possible RV dysfunction • Respiratory Considerations: protective mechanical ventilation strategy / lung ultrasound / POCUS • Renal Dysfunction -Role of renal replacement therapy

Postoperative Care of suspected/confirmed Cardiac Surgery COVID -19 patients • Attention to patient transportation by personnel with PPE • Antiemetics administration at end of surgery and prior to weaning • If possible, extubation in OR -N95 mask applied to patient afterwards • Proper disposable equipment and medical waste should be discarded as per guidelines and protocols