key: cord-0937779-ti7g7b42
authors: Fiorelli, Silvia; Menna, Cecilia; Piccioni, Federico; Ibrahim, Mohsen; Rendina, Erino Angelo; Rocco, Monica; Massullo, Domenico
title: The cutting edge of thoracic anesthesia during the 2019 coronavirus disease (COVID-19) outbreak
date: 2020-06-07
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.05.042
sha: 67f48f92637c93159d4ad2e2fdb0126500320703
doc_id: 937779
cord_uid: ti7g7b42

Coronavirus disease 2019 (COVID-19) has quickly spread globally, causing a real pandemic. In this critical scenario, lung cancer patients scheduled for surgical treatment need to continue to receive optimal care while protecting them from an eventual severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Adequate use of personal protective equipment (PPE) during aerosol-generating procedures (AGPs) and a COVID-19 specific intraoperative management are paramount in order to prevent cross infections. New suggestions or improvement of existing contagion control guidance are needed, even in case of non-symptomatic patients, possibly responsible for virus spread.

Coronavirus disease 2019 (COVID-19) has spread rapidly throughout Wuhan (China) and worldwide 1 , giving rise to a public health emergency. This outbreak was declared a pandemic by the World Health Organization (WHO) on March 11th 2020 2 . The pathogen responsible has been identified as a novel enveloped RNA beta-coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 3 . This infection causes clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus (SARS-CoV) 1 . SARS-CoV-2 mostly spreads via droplets, contact, and natural aerosols from human-to-human. Although the transmission source of COVID-19 is mainly throughout infected symptomatic patients 4 , human-to-human transmission can occur during the asymptomatic incubation period of COVID-19 (ranging from 2 to 14 days) 5, 6 . The determined viral load was found to be comparable in asymptomatic and symptomatic patients with COVID-19, with a possible viral transmission from symptomless or minimally symptomatic patients to other persons 7, 8 .

Elective surgery deferral along with adopting workflow patterns to control infection pathways have been introduced to prevent nosocomial COVID-19 spread 9 . In this perspective, non-emergency surgery in COVID-19 positive patients should be postponed. In spite of this critical scenario, lung cancer patients scheduled for surgical treatment need to continue to receive adequate care while protecting them from undergoing surgery during a simultaneous SARS-CoV-2 infection 10 . In fact, during the COVID-19 outbreak period, improvement of contagion prevention and control has becoming a paramount issue in this novel healthcare settings. The increased awareness of individual protection, sufficient personal protective equipment (PPE), and proper promptness and response would play an important role in lowering the risk of hospital acquired-infections 11 . Aerosolgenerating procedures (AGPs) such as endotracheal intubation and airway surgical or endoscopic procedures may put health care workers (HCWs) at high risk of contagion 12 . Moreover, due to lung separation need, airway management for thoracic surgery requires high-complexity strategies that can expose anesthetists to increased risk of infection.

In light of above-mentioned issues related to the new COVID-19 pandemic, perioperative patient management should be systematically re-arranged. In order to minimize cross-infection risk, new advice or reinforcement of existing infection control guidelines are needed, considering every patient undergoing surgery as potentially positive for infection.

Although no studies have been published yet to support these recommendations due to the exceptional shortness of time of the current emergency, these perspectives are developed by an expert team working in a high-volume thoracic surgery center during COVID-19 outbreak and could be valuable to prevent nosocomial infections in this challenging situation. This manuscript aims to provide suggestions and special features of anesthetic management for thoracic surgery during the COVID-19 surge, considering also so far published recommendations.

Before hospitalization, patients scheduled for lung surgery should be carefully screened for a possible SARS-CoV-2 infection throughout a telephone interview. A previous contact of the patient with confirmed case of COVID-19 in the last two weeks or the presence of any family members with symptoms was investigated. Symptoms such as fever, cough, sore throat, burning eyes, widespread pain, breathlessness, asthenia, and diarrhea or a provenience from a high-risk region were also inquired. In the case of one positive response, patients should undergo reverse transcriptase-polymerase chain reaction (RT-PCR) to detect SARS-CoV-2 RNA. This test should be performed in both nasopharyngeal and oropharyngeal swabs in order to improve the detection rate of nucleic acid and reduce the false negative 13, 14 In the case of RT-PCR unavailability, chest CT has shown high sensitivity, and it could be a useful and fast diagnostic tool in patients with clinical and epidemiologic features compatible with COVID-19 infection 15 , although its role as a screening test is still debated 16, 17 . In the case of all negative responses to the questionnaire, COVID-19 related blood tests anomalies such as lymphopenia, increased values of C-reactive protein (CRP), lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), and D-dimer, as well as low concentrations of serum albumin and hemoglobin 18 or X-ray abnormalities (bilateral or peripheral consolidation and/or ground-glass opacities) 19, 20 also require further investigations such as RT-PCR and CT-scan 21 . If SARS-CoV-2 infection is diagnosed, surgery should be postponed (at least 7-14 days from the end of symptoms and after negative swab result). An algorithm summarizing the above-mentioned suggestions for patients' screening for COVID-19 is shown in Figure 1 .

With the growing of pandemic, some authors have also suggested that elective patients should undergo RT-PCR tests for COVID-19 prior to surgery 22, 23 . This intervention could be an effective strategy to prevent possible cross-infection in HCWs and patients in the perioperative setting in high-prevalence areas, always taking into consideration a possible false-negative result.

Despite this critical situation, lung malignancy remains the commonest cause of cancer death globally, representing a relevant healthcare burden 24 . Adequate care should continue to be guaranteed to these patients, and inappropriate surgical delay should be avoided. Nevertheless, as the spreading of the pandemic, healthcare resources could be exhausted in high-prevalence areas, making elective surgery difficult to perform even in cancer patients, especially if ICU is expected to be required in the postoperative course. During outbreak period, the management of patients requiring major oncological surgery within adapted and often short timeframes is a challenging concern. In fact, a possible increased susceptibility to COVID-19 due to immunosuppressive changes around surgery should be considered. This condition can accelerate and exacerbate infection progression, increasing the risk of postoperative complications and mortality 25, 26 . The surgical indication should be evaluated carefully, taking into account all the above-mentioned aspects and evaluating a risk/ benefit ratio for each situation based on a multidisciplinary discussion.

Before hospitalization, since hospital resources could be exhausted, it should be ensured that they are still available (e.g. hospital bed, ICU). During hospital stay, any patient with suspected newonset of fever or respiratory symptoms should be isolated (in a single negative pressure room) and investigated thoroughly to rule out SARS-CoV-2 infection 27 .

During the hospital stay the number of visitors should be restricted. in order to limit contagion.

Social distance in the common areas should be based on current recommendations provided by the Centers for Disease Control and Prevention for social distancing, reducing the number of people and trying to maintain a distance (approximately two meters) between individuals when possible 23, 28 . All visitors to the hospital should also wear face masks and use 75% alcohol hand sanitizer prior to entry 29 .

In the hospital setting, standard precautions presume that every patient is potentially infected or colonized with a pathogen that could be transmitted to HCWs 30 . For patients suspected to be infected or colonized with infectious agents, additional control measures to effectively prevent transmission are required 31 . Airborne precautions are applied by personnel involved in AGPs (tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy) 32 in order to prevent the spread of infectious agents transmitted by the airborne route. Since airway viral load is estimated to be very high 6 , personnel involved in AGPs are at high risk of contagion. In the course of COVID-19 outbreak, new recommendations or reinforcement of existing infection control guidelines to protect both patients and HCWs are required 31, 32 During the widespread SARS outbreaks in 2003, the human transmission of SARS-CoV also highlighted the need for vigilance and improvement of infection control measures 31 . In fact, a systematic review focused on the SARS-CoV epidemic highlighted that HCWs performing endotracheal intubation had a higher risk of viral contagion (OR 6.6, 95% CI 2.3-18.9) than other AGPs such as non-invasive ventilation (OR 3.1, 95% CI 1.4-6.8), tracheotomy (OR 4.2, 95% CI 1.5-11.5), and manual ventilation before intubation (OR 2.8, 95% CI 1.3-6.4) 33 .

AGPs should be performed in a negative pressure/airborne isolation operating room (OR) 32, 34 . If negative pressure is not available, positive pressure system and air conditioning should be turned off 35 . Suggested procedures for putting on and removing PPE [39] [40] [41] [42] are shown in Figure 2 .

During this outbreak period, standard precautions are applied in the general population (avoid mass gathering, keep distance greater than one meter between two people). In the healthcare settings, these precautions have great importance in the light of a possible viral transmission during incubation period or from asymptomatic patients. Several recommendations have been established for COVID-19 infected or suspected patients, and standardized protective measures are also suggested for OR procedures in non-suspected patients. Therefore, extensive COVID-19 specific anesthesia guidelines need to be developed and applied to prevent nosocomial cross-infections.

Moreover, thoracic anesthesia requires advanced airway management and lung isolation, thus additional precautions are mandatory 42, 43 .

The use of a double lumen tube (DLT) for one-lung ventilation (OLV) is suggested in this critical setting. DLTs previously showed to be the primary choice for OLV in 95% of patients due to its ease and fastness of placement 44 . Moreover, DLTs can be checked by auscultation and observation of chest wall movements, differing from bronchial blockers (BBs) that require bronchoscope use for their positioning. During the COVID-19 outbreak, bronchoscope routine utilization is not recommended 4, 45 , and its use should be restricted in order to minimize the need to open and manipulate the airway. Bronchoscopy should be reserved for difficult airway management or troubleshooting tube misplacement that cannot be solved with minimal DLT movements 46 . If bronchoscopy is required, a disposable tool should be preferred 42 .

Furthermore, transthoracic ultrasound (US) scanning has been proposed as a valuable tool to confirm DLT placement. In detail, the correct position of DLT can be predicted when, during OLV, lung US revealed proper lung isolation (absence of 'lung sliding' and presence of 'lung pulse' seen on the side of surgery and 'lung sliding' sign seen on opposite side) with normal airway pressure and oxygenation 47 .

All the procedures that could cause aerosolized virus spreading should be avoided. A 3-minutes preoxygenation and rapid sequence induction in order to avoid bag-mask ventilation are also suggested. The more expert anesthetist should perform endotracheal intubation using a videolaryngoscope, preferably with disposable blades and a separate screen to minimize patient contact 40 . A complete neuromuscular blockade should be ensured to prevent cough reflex during endotracheal intubation. Rocuronium (1 mg/kg) may be preferred to succinylcholine as muscle relaxant for the absence of major adverse effects and for its longer half-life, which effectively prevents coughing or vomiting that might occur when the shorter-acting neuromuscular-blocking agent subsides after failed intubation attempt 35, [48] [49] [50] [51] .

Bronchial and tracheal cuffs should be inflated immediately after DLT placement to avoid leakage. If postoperative ventilation is required, it would be advantageous to use a BB, avoiding the necessity of a catheter exchange and minimizing airway manipulation at the end of surgery.

According to standard recommendations, awake fiberoptic intubation with single-lumen endotracheal tube and BB is also suggested for predicted difficult airway 55 , a quite frequent occurrence in thoracic anesthesia (10.8%) 44 .

Extubation, being a high-risk AGP, should be performed in the OR with minimal agitation and coughing to limit virus spread 56 . The use of barrier devices over the patient's head, such as clear plastic drapes or an aerosol box, could be helpful and effective in limiting aerosolization and droplet spray that can cause contamination of the surrounding surfaces and HCWs during extubation 57, 58 .

A summary of suggested procedures that can be applied to all patients undergoing thoracic anesthesia in this critical period of COVID-19 outbreak is shown in Table 1 4, 12, 30, 32, 34, 37, 40, 42, 49, 59 .

Although regional anesthesia techniques are not considered AGPs and require standard precautions, since general anesthesia is needed for thoracic surgery anesthetic management, respiratory masks should be used during the procedures 60 Having the US machine numerous surfaces that can serve as viral droplet reservoirs, protecting it with a single-use plastic transparent cover can help to prevent its contamination. The US probe should also be covered along its entire length with a disposable probe sheath 63 .

In this critical scenario, it is generally recommended that any additional analgesic block techniques should be avoided if adequate pain management can be achieved using alternate regimens such as systemic analgesia 60 . Nevertheless, a risk/benefit ratio should be evaluated in each situation, considering that thoracotomy is one of the most painful surgical access and that loco-regional techniques are effective in pain management, reducing opioid use and related adverse effects, such as respiratory depression, sedation, nausea, and vomiting 64 . In our experience, applying the abovementioned suggestions for regional analgesia, performing a minimally invasive peripheral technique such as the erector spinae plane block (ESPB) as part of a multimodal pain management, could be considered a safe and effective procedure for postoperative pain after lung surgery 65 and can be a viable choice also during pandemic. Moreover, since severe acute postoperative pain represents the most important risk factor for chronic pain after thoracic surgery with a worse quality of life, pain management after surgery should not be disregarded even during this current critical situation 66 .

For airway endoscopic operative procedures, specific precautions could be adopted because of the increased risk of airborne viral transmission. During these high-risk AGPs, the entire staff should wear appropriate PPE and they should be performed in the OR with a negative pressure/airborne isolation or turning off positive pressure system and air conditioning.

Rigid bronchoscopy requires general anesthesia. Topical anesthesia is also recommended to reduce upper airway reflexes and sedative agents' requirement. In order to minimize the leak, bronchoscope silicone caps and packing of the oropharynx can be helpful 67 . HEPA filters application on each interface to ventilator is also suggested. In order to avoid an eventual airborne spread and to limit contamination, a protective transparent drape ( Figure 3C ) (e.g. covering for portable gamma camera system) can be employed limit contamination without interfering with the procedure 57 .

Finally, the airway management advised for flexible bronchoscopy is the use of controlled ventilation through positioning a supraglottic airway device (SGA). After achieving deep sedation, SGA insertion, and connection to breathing circuit, the bronchoscope is inserted into the suction port of the swivel connector ( Figure 4 ). SGA allows for better airway support and gas exchange while sharing the airway with flexible bronchoscopy 68 . Topical anesthesia use remains a necessary approach 69 . HEPA filter use is also suggested.

After surgery, patients should not be addressed to common areas such as the recovery room or postanesthesia care unit (PACU) 70 . Postoperative surveillance should take place in the preoperative holding area adjacent to OR. Being oxygen supplementation previously identified as an independent risk factor for super-spreading nosocomial outbreaks 71 , during oxygen delivery, patients should wear a surgical face mask to prevent droplet transmission, and nasal cannula should be applied preferably. Patient transport, especially if postoperative mechanical ventilation is required and the patient is kept intubated, could lead to potential non-observance of infection control measures, and requires special carefulness. During intubated patients' transfer to ICU, HCWs should wear adequate airborne PPE, use a single-patient respiratory bag with HEPA filter on the endotracheal tube, and avoid unnecessary disconnections 35, 72 . A "security team" to lead and guarantee clearance of bystanders for the whole designated route ahead of transporters is also advisable 72 .

In the course of COVID-19 pandemic, perioperative management of patients scheduled for lung cancer surgery needs to be reassessed. Careful preoperative screening is necessary in order to identify possible SARS-CoV-2 infections. Because of the high complexity of airway management for thoracic anesthesia, intraoperative precautions for contagion prevention should be implemented with specific recommendations for healthcare providers and with universal application to all patients, even in non-infected population, in order to prevent hospital-acquired infections in OR setting.

During the observation period (28 February-3 April), 105 patients underwent elective thoracic surgery. All patients were submitted to the anamnestic questionnaire before hospitalization. DLT was used in 100 patients, whereas 5 patients were managed throughout a single-lumen tube and a BB because of predicted difficult airways. All BB were positioned with bronchoscope use. Among the patients managed throughout DLT, 10 patients required bronchoscopy due to tube malposition.

No HCWs or patients undergoing procedures reported SARS-CoV-2 infection in the postoperative course in our high-volume thoracic surgery center. We believe the accurate preoperative selection of patients combined with the adherence to the above-mentioned infection control procedures specific for thoracic surgery has yielded positive outcomes. -Set the ventilator to standby before each circuit disconnection -Alveolar recruitment maneuvers and pulmonary re-expansion tests performed by circle breathing system -Extubation at TOF Ratio> 0.9 -Face mask repositioning to the patient after extubation -Postoperative surveillance in preoperative holding area adjacent to OR (avoiding the common areas, e.g. recovery

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