Perioperative Management of Patients with COVID-19 infections

Take home message

 

  • Healthcare workers are at high risk for infection with the highly contagious COVID-19 infection. So, you should be well prepared and protected with proper donning and doffing of PPE.
  • Elective procedures have been postponed or rescheduled in many centres
  • Preoperative routine screening for COVID-19 infection using a checklist, RT-PCR, CT, or antibodies should be considered.
  • Golden measures to be prepared include planning ahead, increasing ICU capacity, the proper team preparing and training, floor and hospital planning, using schematic checklists, preparing equipment and medicines needed, briefing and debriefing and ensuring staff wellbeing.
  • Perioperative management should be provided by the most experienced staff.
  • Limit the number of staff involved.
  • Negative rooms, if available, should be considered particularly during the aerosol-generating procedures.
  • Nonintubated cardiac or thoracic procedures would leave the airway open to the atmosphere with risks for aerosol transmission.
  • Elective intubation should be considered in all COVID-19 patients.
  • Innovative and untrusted PPE measures should be validated before use.
  • Identify the indications for using the BB or DLT if lung separation/isolation is required.
  • One lung ventilation is challenging particularly in the light of two phenotypes of COVID-19.
  • A focused TOE exam should be limited to the selected cases.
  • The decision on extubation should be individualized based on the infectivity status, patient’s conditions and available resources.
  • Caution should be exercised after surgery for patient transferring and decontamination procedures.
  • Maintain healthy non-clinical environment far away from the caring of the patients during the COVID-19 pandemic.
  • Finally, we hope these recommendations would be helpful in everyday practice during the era of COVID-19 outbreak.

Summary:  EACTA webinar on Perioperative Management of Patients with COVID-19

Dr. Hans-Christian Zaun, Ph.D. Scientific Advisor, MULTILEARNING GROUP.

Moderated by Dr. Mohamed El Tahan of Mansoura University, Egypt, and the University of Damman, Saudi Arabia.

The speakers include Dr. Massimiliano Sorbello of San Marco University, Catania, Italy; Dr. Fabio Guarracino, Pisa University Hospital, Italy; Dr. Mert Senturk, İstanbul University-Cerrahpaşa, Istanbul, Turkey; Dr. Irene Ovira, from Barcelona, Spain.

Dr. Sorbello began the webinar on the lessons learned from airway management of COVID-19 patients, and his experiences in Italy.  He starts with a brief recap of the COVID-19 outbreak in Italy and a remembrance of the 150 health care workers who died. Dr. Sorbello notes that there is still a lot that is unknown about COVID-19, particularly about its transmission by way of aerosols and how this affects the necessary steps in preventing infection of medical staff in the clinical setting. He reviews numerous studies looking at personal protective equipment (PPEs) and stresses that the prevention of aerosol-based infection is imperative in airway management and anesthesiology. He further emphasizes the importance of proper donning and doffing of PPEs, especially as doffing results in an increased risk of self-contamination. Dr. Sorbello continues by discussing the differences in clinical manifestations of COVID-19 from other respiratory diseases. He reviews recommendations on the numerous procedures such as pre-oxygenation, intubation and extubation that includes informative videos.

Then Dr. Guarracino discusses proper preparedness for the Cardiac Anaesthetist. He reviews the importance of both screening patients before surgery and protective measures needed in the operating theatre. He reiterates Dr. Sorbello`s position on the importance of proper PPE management, particularly the donning and doffing and recommends that teams run simulations with the most experienced staff supervising. He continues his discussion by presenting recommendations for various procedures that include intubation, extubation, non-intubation surgeries, among others. Dr. Guarracino concludes his presentation by reminding viewers that COVID-19 is still spreading and that all anesthesiologists will most likely have to deal with these issues in the future.

Dr. Mert Senturk continues by discussing the proper preparation of staff for thoracic surgeries. He gives recommendations both on the appropriate set up of the operating theatre and preparation for the airway management team. He also discusses the importance of testing and recommends that the CT scan should be a part of the diagnosis due to the problem of false-negative results of the swab tests. He stresses that while waiting for diagnostic results to confirm COVID-19, we must treat all patients as potentially COVID-19 positive. Dr. Senturk continues his discussion by reviewing numerous recommendations for preparing both operating theatres as well as the patient. The remainder of Dr. Senturk’s presentation reviews multiple procedures that include algorithms for thoracic intubation and general indicators for bronchial blockers.

Finally, Dr. Irene Rovira discusses the situation in Spain and the numerous preparations of her hospital in Barcelona undertook in preparing for the influx of COVID-19 patients. These preparations included freeing up ICU beds, coordinating multidisciplinary teams, preparing equipment and reviewing various recommendations including checklists for the donning and doffing of PPEs, ventilation procedures, and COVID-19 patients.

After several questions about screening recommendations and heparinization issues, Dr. El Tahan concluded by briefly reviewed the guidance given by the speakers.

After joining this webinar you will better understand:

  • Essentials of airway management in patients with COVID-19 infection;
  • Preparations for perioperative care of patients with suspected or confirmed COVID-19 infection who undergoes cardiac or thoracic surgery;
  • Principles of care of the critically ill COVID-19 patients.

Target Audience:
Cardiac, thoracic and vascular anaesthetists, intensivists, perfusionists, general anaesthetists, anaesthesia certified nurses, nurses, interns and medical students.

The webinar is free of charge.

To join it, you should be registered in the EACTA database in order to have access to the e-academy (no need to pay the members’ fee, as the content is available for free). Please click here and then on ‘create account’ in order to gain your credentials.
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Click here to see the recordings of the webinar, published in open access
Check below the programme, the speakers and replies to questions not adressed during the live event

Chair of the Webinar and Scientific Moderator: Mohamed R. El Tahan (Chair of the EACTA Education Committee)Mansoura, Egypt

  • Lessons Learned from Airway Management of COVID-19 Patients. Italian Experiences- Massimiliano Sorbello, Catania, Italy
  • Cardiac Anaesthetist: How to Prepare for COVID-19 Patients? - Fabio Guarracino, Pisa, Italy
  • Thoracic Anaesthetist: How to Prepare for COVID-19 Patients? - Mert Senturk, Istanbul, Turkey
  • Cardiothoracic Intensivist: How to Prepare for COVID-19 Patients?- Irene Rovira, Barcelona, Spain
  • Wrap up and Take Home Message - Mohamed R. El Tahan, Mansoura, Egypt

Bougie = Tracheal Introducer is suggested as tool to maximize first pass success (see Sorbello et Al, Anaesthesia 2020 doi: 10.1111/anae.15049.; Driver et Al, JAMA 2018 doi: 10.1001/jama.2018.6496.). single use bougies are preferable, and actually Frova introducer is the best performing single use introducer (Hodzovic et Al, Anaesthesia 2003 10.1046/j.1365-2044.2003.02871.x)

Point of COVID-19 intubation is maximize first pass success, to avoid troubles from repeated attempts (+ risk of infection; + risk of desaturation and hemodynamic complications). As a consequence, we recommended videolaryngoscope + tracheal introducer, (see Sorbello et Al, Anaesthesia 2020 doi: 10.1111/anae.15049). taking also account of from Driver’s study (Driver et Al, JAMA 2018 doi: 10.1001/jama.2018.6496.) and clinical experience.

It has been suggested via conjunctival mucosa, given the (discussed) evidence that SARS-CoV-2 transmission occurs also via small droplets=aerosolization (airborne transmission – see Wilson NM, et Al. Anaesthesia. 2020 Apr 20. doi: 10.1111/anae.15093). For Aerosol Generating Procedures eye protection is globally recommended (goggles, face shield if not PAPR). Videolaryngoscope is suggested also for this purpose, as it increases distance from patient’s airway (see Sorbello et Al, Anaesthesia 2020 doi: 10.1111/anae.15049).

1) Anesthesia machine should be covered with plastic covers. Antiviral filter is highly recommended. HME filters should be safe if high quality (protection 99.9%) and equipped between endotracheal tube and respiratory circuit AND on expiratory limb of respiratory circuit on ventilator (Kamming D, Gardam M, Chung F. Anaesthesia and SARS. Br J Anaesth. 2003; 90: 715-8.). in similar assembly, etco2 sampling line is protected by the antiviral filter, you should not need a second filter. I have serious doubts that epidural filter is suitable for aerosolized particles.

2) We are slowing building phase 2. Patients should be admitted for elective surgery after negative swab (x 2) and evidence of quarantine between swabs and surgery. Having serological tests would obviously be recommendable. CT scan is high sensible, and faster than swab. We used for triage, considering COVID+ a patient if the CTscan was suggestive despite a negative swab (false negatives up to 30%). US also helpful.

Any non-tested patient, especially if respiratory symptoms, should be considered positive until contrary proof

Good question, I do not know .. I do not thnk that anybody would say a concrete dose to stop soughing. I have a good experience with 0.5 mikrog/kg (there is also a study); for remi about 0.1 mikrog/kg.. (Good review: Tung et al : Br J Anaesth. 2020 Feb 22. pii: S0007-0912(20)30012-X. doi: 10.1016/j.bja.2019.12.041

Speakers:

Good idea: If the patient is not already intubated, this can be a good idea.. At the end, get the blocker simply back

Speakers:

Probably for a long time, we will “consider” every patient as covid(4), meaning more PPE.
And time to think about negative pressure OR’s.

Speakers:

Actually they say yes (but somehow impossible in my hospital). They say it is only a “switch” from (+) to (-). Or you can increase the pressure of other OR’s to create a negative pressure in the functioning OR. If not possible: 1. Increase the level of PPE; 2. Close the doors to avoid further dispersion.

Speakers:

1.We have used rocuronium for RSI; 2. The patient has the risk of heavy secretion. I would prefer sugammadex

Speakers:

Good question, thx. It is logical that manipulating the lung is associated with a risk of contagion. For me, VATS makes sense… and therefore yes: OLV mandatory

Speakers:

In our experience the incidence of AKI requiring CRRT was low and the clotting of filter/circuit was lower than usual. Taking in to account that the 2 patient with CRRT were on NFH for other reason. But COVID-19 is a procoagulant disease, so all our patients received prophylactic LMWH and therapeutic if DD > 5000.

Speakers:

In our protocol we start with Kaletra very early, usually in the emergency room or ward and treated during 7-14 days. We add Tocilizumab in case of severe Pneumonia PaO/2/FiO2 < 200, need for IMV or increase in RPC, DD and ferritin.

Speakers:

A patient with preop negative swab is considered NO COVID. So we should wear normal protections. However, at my Institution we wear ffp2 and face shield during AGP in these patients (compared to full PPE in COVID positive) as swab test is known not to be 100% perfect

I was wearing a full-face shield. I think the light was not very good in the room, but if you look at the picture carefully you can see it. When wearing a gown the neck is not covered, but this is ok. After doffing we undergo spray disinfectant.

Very good question.
We should refer to the manufacturers’ recommendations dedicated to cleaning the probe in Covid patients. All Companies provided specific recommendations. We follow Philips’ for example.
The whole probe should be treated appropriately in order to guarantee safety of the next patient and of the probe itself (no damage).

Thank you, very important question.
We do not use it routinely. We balance benefit/risk ratio, and when we use it we go for a focused exam.
We definitely use it in type A Ao dissection, complicated AMI, endocarditis, valve repair.
The risks of aerosol generation with TOE are high in a spontaneously ventilating patient; in a tracheally intubated patient with the airways secured the risks are very much reduced.

As I said during the webinar, ACT is ok but I prefer combining with ROTEM or TEG and look at their agreement. In some cases ACT is “ok” but ROTEM shows INTEM and HEPTEM are equal. In these cases ATIII and more heparin may help.

Very important question.
We use it a lot. Though no diagnostic sign has been validated, the US appearance of pleura and lung are very typical.
Last Friday I saw a patient with positive swab and shortness of breath: the lung US was normal, only bilateral massive pleural effusion was present. The lung CT scan was normal. The patient has a cancer (and a positive swab).

Yes you are right. APTT is the currently used coagulation test. However, in ICU we often use also POC in addition in ECMO either because it is quicker than lab, either because it shows a complete physiology of clot phenomenon.

I think so, if your logistics allow this to happen. Otherwise we should have a well-designed pathway for suspected or diagnosed Covid 19 pt to apply on a case by case approach.

Very good point, thanks.
We did all them percutaneous, when the patient was considered no longer at risk of prone ventilation (usually later than day 8), in negative pressure ICU room

Event Details
  • Start Date
    May 4, 2020 5:00 pm
  • End Date
    May 4, 2020 7:00 pm
  • Status
    Expired
  • Category