key: cord-0753343-ud1pc9wb authors: Hu, Chunxiao; Wang, Guilong; Zhou, Difei; Wang, Wei; Qin, Zhong; Wang, Yanjuan; Chen, Jingyu; Liu, Hong; Li, Quan; Huang, Dongxiao title: The Anesthesia Management of the First Lung Transplant Case for Patient with COVID-19 Respiratory Failure date: 2020-06-10 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.06.011 sha: c082f4c1acb4288053075c249f13aadcf01494dd doc_id: 753343 cord_uid: ud1pc9wb nan The novel coronavirus that was first detected in China at the end of 2019 and there were 3,517,345 confirmed coronavirus disease 2019 (COVID- 19) cases and 243, 401 deaths worldwide as of May 5, 2020. including United States. [1] [2] [3] According to Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7), 4 pathological findings from limited autopsies and biopsy studies indicate: variable consolidations are presented in the lungs, and organization of alveolar exudates and interstitial fibrosis are also present. Some COVID-19 patients presented with severe adult respiratory distress syndrome (ARDS) and irreversible lung injury, even when their SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay has become negative. For these patients, instead of using long-term extracorporeal membrane oxygenation (ECMO), the lung transplant might be an alternative option. Due to the uncharted territory of COVID-19 with unknown outcome of lung transplant, no lung transplant had performed before this case. We report the world's first double lung transplant for a patient infected with novel coronavirus. Patient is a 59- year-old male with confirmed COVID-19 presented with end stage respiratory failure and irreversible lung injury despite invasive mechanical ventilation and veno-venous ECMO (V-V ECMO). His height is 170 cm and weights 70 kg. The chest computer tomography (CT) shewed bilateral multifocal ground-glass opacities with patch consolidations (Figure 1 ). The chest X-ray before surgery showed bilateral lung involvement with "white out" and multifocal consolidation ( Figure 2 Although ECMO can serve as the life-saving rescue therapy for refractory respiratory failure in the setting of acute respiratory distress syndrome (ARDS) caused by COVID-19, the mortality rate is 45% according to the Extracorporeal Life Support Organization (ELSO) registry (https://www.elso.org/Home.aspx). However, there are study reported the mortality rate as high as 83%. 6 COVID-19 patients who developed ARDS and refractory respiratory failure are treated with mechanical ventilation and ECMO. 11 There are significant numbers of these patients were become ECMO dependent. Even the patients who were able to be weaned off from ECMO, their lung injuries are irreversible. Lung transplant becomes an alternative option for these patients just like all the other end stage lung injury patients who require lung transplant. The COVID-19 patients should be registered on national lung transplant registry. Since this is a new disease without effective treatment and the outcome is unknown, patients should be given sufficient time for the lungs to heal. Although the SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay was negative for three times from both nasopharyngeal swabs and bronchoalveolar lavage samples, it has been reported that the coronavirus test become positive again days after patients had recovered from COVID-19. 12 This could be explained by the possible false negative tests, discontinuation of antiviral drugs and rebounding from residual viruses. 12, 13 Because the lung transplant is a resource-limited field, it is important to balance the risks and benefits. The current evidence supports that younger recipients with single system disorders who will likely have better outcomes. 14 The protective measures for health care providers in the perioperative settings is another important aspect in managing COVID-19 patients. [15] [16] [17] [18] During the 2003 SARS outbreak in Ontario, Canada, 51% of cases were healthcare workers. Healthcare worker involvement with tracheal intubation conferred a 13-fold higher relative risk ratio for acquiring SARS infection when compared to healthcare workers not participating in tracheal intubation. 19 A more recent publication from the Chinese Center for Disease Control and Prevention (Beijing, China) reported that as of February 11, 2020, there were 1,716 healthcare workers diagnosed with COVID-19 out of 44,672 confirmed cases, although most of the infected healthcare workers were confined to the initial epicenter of the outbreak (Hubei Province, China). 20 Even the patient's COVID tests have become negative, the hospital still mandated using standard Level 3 protection (Table 1) . Double masks with N95 inside and surgical mask outside, gowns, and double gloves should be worn by the intubation team. The person who is performing the intubation should wear a third pair of gloves and remove them immediately after intubation. A dedicated OR only for patients with COVID-19 equipped with a negative pressure system should be used. If there is no negative pressure OR unavailable, the positive pressure system and air conditioning must be turned off. Anesthesia equipment, supplies, and medications must be used only for the patient exclusively. Anesthesia supplies that directly contact the patient's skin or mucosa should be single use, including the video laryngoscope blades, endotracheal tubes, anesthesia masks, filters, breathing balloons, suction tubes, and/or catheters, end-expiratory carbon dioxide sampling tubes, water traps, etc. A closed airway suction system is recommended to reduce aerosol generation. All healthcare workers --+ ++ * Based on the regulations established in Wuxi people's Hospital with modifications. + mandatory; -not needed; ± decision made according to the work scenario; ±! choice between isolation gown or protective clothing is decided based on the local resources for level Ⅲ protection; ++ means double gloves or shoe covers. China Novel Coronavirus I, Research T China Novel Coronavirus I, Research T. A novel coronavirus from patients with pneumonia in China Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention National Health Commission and National Administrative Office of Chinese Tradition Medicine: National Recommendations for Diagnosis and Treatment of Pneumonia Caused by 2019-nCoV Donor Lung Explantation and Protection Specifications for Lung Transplantation in China Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study COVID-19, ECMO, and lymphopenia: a word of caution Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension Surgical techniques: lung transplant and lung volume reduction Extracorporeal Membrane Oxygenation for Coronavirus Disease Discontinuation of antiviral drugs may be the reason for recovered COVID-19 patients testing positive again Post-discharge surveillance and positive virus detection in two medical staff recovered from coronavirus disease 2019 (COVID-19), China Lung transplantation: a review of the optimal strategies for referral and patient selection Perioperative Management of Patients Infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan's Experience Practical recommendations for critical care and anesthesiology teams caring for novel Coronavirus (2019-nCoV) patients Infection prevention measures for surgical procedures during a Middle East Respiratory Syndrome outbreak in a tertiary care hospital in South Korea Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases