In a crisis, be aware of the danger – but recognize the opportunity.
– John F. Kennedy

The coronavirus disease (COVID-19) has posed challenges to healthcare systems globally and will do so for even years. The disease’s risk for both patients and healthcare workers has transformed medical practice. However, anesthesiologists are given the chance to provide the safest type of anesthesia to the patients, simultaneously safeguarding themselves and other OT staff from being susceptible to the virus.

Many studies have shown decreased incidence of intra and postoperative complications in COVID patients undergoing surgery under regional anesthesia and reduced transmission of the disease to the theatre personnel.

The European and American Societies of Regional Anaesthesia have jointly declared COVID-19 recommendations stating that regional anaesthesia should be the best choice compared to general anaesthesia whenever possible.  Besides, recommendations for performing regional anaesthesia during the pandemic have been published. The Royal College of Anaesthetists and Association of Anaesthetists also suggest using regional anaesthesia where possible and safe in order to safeguard primary drugs required at the time of critical care of COVID-19 patients.

Advantages of regional anaesthesia over GA in patients with COVID:

• SARS-CoV-2 is majorly transmitted through respiratory droplets and fomite transmission. Airway manipulation is linked with some of the highest rates of coronavirus transmission, and it is recognised that minimising aerosol-generating procedures like mask ventilation and endotracheal intubation are desirable.  During extubation, patients can have coughing & retching, which again can spread the virus extensively.
• Administration of GA in patients with symptoms of active COVID infection is sometimes associated with complications like intraop & postop desaturation, hemodynamic instability, delayed recovery, need for postop ventilation/ICU care, worsening of disease symptoms, etc. These problems can be avoided if the surgery is performed under regional.
• Better management of time, resources, and financial costs of personal protective equipment (PPE), theatre time and surgical equipment
• Safer option in the absence of negative-pressure operating rooms
• Better preservation of immune function when compared with general anaesthesia
• Improved postoperative analgesia
• Decreased usage of intravenous drugs like propofol , muscle relaxants, and opioids, which may be in short supply
• Minimising the need for postoperative monitoring leading to better utilisation of both ward and ICU beds as well as reducing exposure to nursing staffs.
• Decreased incidence of postoperative complications like cardio respiratory failure, pulmonary thrombo-embolism, neurovascular complications, etc.
• Early ambulation and discharge of the patients

Patient selection:

• Patients should not be in respiratory distress
• Stable on room air or requiring minimal o2 support
• Absence of thrombocytopenia and other coagulation abnormalities
• Last but not the least, the patient should be cooperative

Recommendations during surgery

Planning and preparation

Routine investigations as per hospital protocol are done. Consent for regional anesthesia and the possibility of conversion to GA should be explained to the patients

Location

COVID-19–infected patients should be offered care in the operating area and in an airborne-infection isolation room for better results. Operation of the patients can be carried out in a positive pressure room provided there are steps to avoid airflow from the operating room.

Personal protective equipment

Regional anaesthesia procedures are not regarded as aerosol-generating, and hence droplet precautionary measures are not generally suggested. But every staff should wear N95 masks equipped with PPE suits if possible. Patients are supposed to wear surgical facemasks to avoid the disease spread.

Oxygen therapy

The delivery mode and oxygen flow rate impact the chances of aerosol generation and its travelling distance; hence, the oxygen flow should be maintained to a minimum to keep saturation, simultaneously decreasing aerosol generation.

Equipment

Maintain only the necessary equipment, and safeguard the equipment with plastic covers at the time of procedure.

Monitoring and conduct of anaesthesia

There should be extensive testing for block success so that emergency conversion to general anaesthesia is avoided. Viral filters can be applied to carry out respiratory monitoring.

Post-operative care:

• Patients should be observed in the operating room or an isolation room before being transported to a pre-designated area.
• DVT prophylaxis in the form of low molecular weight heparin(LMWH) is recommended for all postoperative patients whenever possible for the following reasons:

1) Increased chances of developing DVTin postoperative patients due to decreased mobility

2) COVID-positive patients inherently are at high risk of developing both arterial and venous thrombosis.

Our experience at Kauvery Hospital so far…

• Since the beginning of the pandemic in March 2020 till the end of May 2021, we have performed emergency and urgent surgeries for about 30 COVID-positive patients. These include 16 caesarean sections, 5 laparotomies, 5 orthopaedic procedures, 2 tracheostomies, one vascular procedure, and one urology procedure.
• Out of these, 24 patients received regional anesthesia in the form of spinal, epidural, or peripheral nerve blocks.
• None of the patients who received regional anesthesia developed any intraoperative or postoperative complications.

Conclusion

As supporters of regional anaesthesia, we encourage the rise in usage of regional anaesthesia at the time of pandemic. Despite the extra advantages to healthcare workers and the hospital, the patient must always stay at the process area. At this time of uncertainty, regional anaesthesia is more favored. Well-defined regional anaesthesia standards and guidance must still be diligently taken into account, and best practices should be given more importance so that nothing is detrimental.

JOINT GUIDELINES ISSUED BY THE AMERICAN & EUROPEAN SOCIETIES OFREGIONAL ANESTHESIA

Dr. Mohamed Najibullah
Consultant Anesthesiologist
Department of Anesthesiology & Pain Management
Kauvery Hospital, Chennai