key: cord-0814137-a7gla4r6
authors: Stewart, Matthew; Thaler, Adam; Hunt, Patrick; Estephan, Leonard; Boon, Maurits; Huntley, Colin
title: Preferential use of total intravenous anesthesia in ambulatory otolaryngology surgery during the COVID-19 pandemic
date: 2020-06-01
journal: Am J Otolaryngol
DOI: 10.1016/j.amjoto.2020.102570
sha: 55a95f0f484a23e9b0b870c5959cbb224c303db4
doc_id: 814137
cord_uid: a7gla4r6

The novel coronavirus (SARS-CoV-2 or COVID-19) pandemic has impacted nearly every aspect of otolaryngologic practice. The transition from office-based evaluation to telemedicine and the number of postponed elective surgical cases is unprecedented. There is a significant need to resume elective surgical care for these patients at the appropriate time. As practices begin to move towards resuming elective and same day ambulatory surgery, safety of both the patient and healthcare team is of paramount importance. Usage of total intravenous anesthesia (propofol and remifentanil) over volatile gas anesthesia (e.g., sevoflurane) may increase the number of patients able to safely receive care by reducing potential spread of the virus through reduction in coughing and significantly decreasing the time spent in the recovery room.

The novel coronavirus (SARS-CoV-2 or COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020 and has since had an unprecedented disruption to medical and surgical care across the world. As the United States begins to resume elective surgical cases, the otolaryngologist is presented with numerous challenges. First, many otolaryngology procedures are aerosolized when involving direct contact with the aerodigestive tract, oral mucosa, or spaces lined by respiratory epithelium (e.g., nasal cavity, nasopharynx, mastoid, etc.)all of which may have significant viral concentration in a COVID-19 positive patient [1, 2] . As a result, the surgeon and operating room personnel may be at risk without adoption of precautions. Second, despite even the most thorough screening of symptoms in patients, there is a growing awareness of asymptomatic carriers of COVID-19 and the possibility of false-negative preoperative COVID-19 tests [3, 4] . In addition, there may be limited access to testing in some areas. The asymptomatic carriers in combination with limited availability and reliability of testing puts health care workers at significant risk of infection, particularly the otolaryngologist operating in tissue with a potentially highly concentrated viral load. In this article, we propose a method of general anesthesia that may help to reduce the risk of viral spread while increasing an outpatient surgery center's capacity to provide care to patients.

We suggest ambulatory surgery centers explore using total intravenous anesthesia (TIVA) using propofol and a short acting opioid such as remifentanil in the setting of COVID-19. We believe utilizing TIVA may reduce upper airway activity and allow for quicker patient recovery times as compared to using volatile anesthesia, increasing the safety of the healthcare J o u r n a l P r e -p r o o f team as well as patients with our rationale explained in detail below. Our suggestions are intended to be supplemental, yielding first to institutional requirements and social distancing guidelines in the midst of the current pandemic.

As widely reported, one of the most common methods of transmission of COVID-19 is via droplet transmission following a cough. Although it is assumed that symptomatic patients displaying fever or cough would likely be identified in preoperative screening, this is not the case for asymptomatic patients. Volatile anesthesia (e.g., sevoflurane or desflurane) represents a group of anesthetics often used for otolaryngologic procedures. This option is cost effective and is typically well tolerated. In the setting of COVID-19, however, there is potential for a significant disadvantage to using volatile anesthesia as compared to TIVA: there is a significantly increased risk of upper airway reactivity, namely a cough, when utilizing volatile anesthesia [5] [6] [7] . Due to this reason alone, our ambulatory surgery center has transitioned all cases to use TIVA over volatile anesthesia for protection of all involved.

Our tertiary care center has seen a significant impact on recovery time and time to discharge for same day surgery patients who receive TIVA over volatile anesthesia. To illustrate this point, we reviewed 59 patients who underwent upper airway stimulation for obstructive sleep apnea at a same day surgery center. Twenty-nine patients received volatile anesthesia with sevoflurane, and 30 received TIVA. There was a 42.5-minute average reduction (p=<.0001) in the amount of time it took a patient to reach an Aldrete score of ≥9/10, indicating the patient had largely recovered from anesthesia and is appropriate to discharge [8] . We suspect that J o u r n a l P r e -p r o o f sevoflurane is more slowly eliminated than TIVA (as propofol and remifentanil) due to its longer half-life in addition to its wider distribution into tissues as compared to TIVA [9] . Further, utilizing TIVA may lead to a decrease in postoperative nausea and vomiting which can also increase the time in recovery for patients who receive sevoflurane [10] . Thus, utilizing TIVA may allow for patients to be discharged faster, and thus have a direct and positive impact on an ambulatory surgery center's ability to provide safe care while efficiently moving patients through the recovery room. This diminishes the recovery time required, may limit the number of staff members involved in the patients care, and may limit the number of unnecessary person-toperson interactions.

Utilization of total intravenous anesthesia with propofol and remifentanil instead of volatile anesthesia may reduce the risk of COVID-19 exposure to healthcare personnel and other patients in the hospital by a decrease in airway reactivity, coughing, and subsequent droplet transmission from asymptomatic and false-negative patients. Further, a significant decrease in recovery time may allow for ambulatory surgery centers to safely provide care to more patients by reducing each patient's time to discharge.

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