Anesthesia Management and Perioperative Infection Control in Patients With the Novel Coronavirus

Abstract

Anesthesiologists have a high risk of infection with COVID-19 during perioperative care and as first responders to airway emergencies. The potential of becoming infected can be reduced by a systematic and integrated approach that assesses infection risk. The latter leads to an acceptable choice of materials and techniques for personal protection and prevention of cross-contamination to other patients and staff. The authors have presented a protocolized approach that uses diagnostic criteria to clearly define benchmarks from the medical history along with clinical symptoms and laboratory tests. Patients can then be rapidly assigned into 1 of 3 risk categories that direct the choice of protective materials and/or techniques. Each hospital can adapt this approach to develop a system that fits its individual resources. Educating medical staff about the proper use of high-risk areas for containment serves to protect staff and patients. Anesthesiologists have a high risk of infection with COVID-19 during perioperative care and as first responders to airway emergencies. The potential of becoming infected can be reduced by a systematic and integrated approach that assesses infection risk. The latter leads to an acceptable choice of materials and techniques for personal protection and prevention of cross-contamination to other patients and staff. The authors have presented a protocolized approach that uses diagnostic criteria to clearly define benchmarks from the medical history along with clinical symptoms and laboratory tests. Patients can then be rapidly assigned into 1 of 3 risk categories that direct the choice of protective materials and/or techniques. Each hospital can adapt this approach to develop a system that fits its individual resources. Educating medical staff about the proper use of high-risk areas for containment serves to protect staff and patients. THE WORLD HEALTH Organization has declared a pandemic with more than 120,000 people diagnosed with the novel coronavirus disease 2019 (COVID-19) and at least 4,200 deaths owing to complications of infection.1World Health Organization. There is a current outbreak of coronavirus (COVID-19) disease. Available at: https://www.who.int/health-topics/coronavirus. Accessed March 10, 2020.Google Scholar The COVID-19 is a zoonosis, a virus that originates in animals but mutated to infect humans.2Zhou P. Yang X.L. Wang X.G. et al.A pneumonia outbreak associated with a new coronavirus of probable bat origin.Nature. 2020; 579: 270-273Crossref PubMed Scopus (12486) Google Scholar Examples of other zoonoses are Ebola virus, human immunodeficiency virus, and salmonellosis.3Baseler L. Chertow D.S. Johnson K.M. et al.The pathogenesis of Ebola virus disease.Annu Rev Pathol. 2017; 12: 387-418Crossref PubMed Scopus (188) Google Scholar, 4Schnittman S.M. Fauci A.S. 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Hayden F.G. et al.A novel coronavirus outbreak of global health concern.Lancet. 2020; 395: 470-473Abstract Full Text Full Text PDF PubMed Scopus (4317) Google Scholar, 11Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (28324) Google Scholar, 12Tang B. Bragazzi N.L. Li Q. et al.An updated estimation of the risk of transmission of the novel coronavirus (2019-nCov).Infect Dis Model. 2020; 5: 248-255Crossref PubMed Scopus (482) Google Scholar The median age of patients diagnosed with COVID-19 pneumonia is 59 years. Children younger than 15 years of age are relatively spared and have either lower infection rates, fewer symptoms, or both. Although estimated mortality rates are less than that for SARS and MERS, the degree of spread is greater.1World Health Organization. There is a current outbreak of coronavirus (COVID-19) disease. Available at: https://www.who.int/health-topics/coronavirus. Accessed March 10, 2020.Google Scholar,13Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China [e-pub ahead of print]. Chin J Epidemiol. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003, AccessedGoogle Scholar,14Sohrabi C. Alsafi Z. O'Neill N. et al.World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19).Int J Surg. 2020; 76: 71-76Crossref PubMed Scopus (2939) Google Scholar This raises global concerns that a greater total number of patients will die from the disease. Disease spread is increased by a relatively long asymptomatic period that ranges from 8 to 15 days but may be as long as 24 days.15Lauer S.A. Grantz K.H. Bi Q. et al.The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application.Ann Intern Med. 2020; https://doi.org/10.7326/M20-0504Crossref PubMed Scopus (3349) Google Scholar,16Bai Y. Yao L. Wei T. et al.Presumed asymptomatic carrier transmission of COVID-19.JAMA. 2020; https://doi.org/10.1001/jama.2020.2565Crossref PubMed Scopus (2761) Google Scholar Healthcare workers are a major route of transmission, similar to the related viruses that cause SARS and MERS.17Wang D. Hu B. Hu C. et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.JAMA. 2020; https://doi.org/10.1001/jama.2020.1585Crossref Scopus (14238) Google Scholar The expected number of secondary cases arising from 1 infected individual is approximately 2 to 3 people at a minimum.16Bai Y. Yao L. Wei T. et al.Presumed asymptomatic carrier transmission of COVID-19.JAMA. 2020; https://doi.org/10.1001/jama.2020.2565Crossref PubMed Scopus (2761) Google Scholar Anesthesiologists are at increased risk of exposure during perioperative management through direct contact, especially tracheal intubation. Transmission can occur from asymptomatic infected individuals. Therefore, healthcare workers should consider all patients as a possible source of infection unless proven otherwise. This is particularly true for anesthesiologists who are commonly in close contact with patients and come into contact with airway aerosols and secretions. Signs and symptoms of COVID-19 infection are fever in 83% to 98%, dry cough in 76% to 82%, and fatigue or myalgia in 11% to 44% of patients.18Del Rio C. Malani P.N. COVID-19-new insights on a rapidly changing epidemic.JAMA. 2020; https://doi.org/10.1001/jama.2020.3072Crossref Scopus (433) Google Scholar The infection progresses rapidly in some patients, with approximately 10% of hospitalized patients requiring mechanical ventilation. Patients who develop acute respiratory distress syndrome, septic shock, refractory metabolic acidosis, coagulation dysfunction, and multiple organ failure have a high mortality rate. Diagnostic criteria for novel coronavirus pneumonia used in the People's Republic of China is detailed in Table 1. The radiographic imaging during the early stages of infection shows multiple small, patchy shadows and interstitial changes in the peripheral lung field.19National Health Commission of the People's Republic of China. Diagnosis and treatment protocols of pneumonia caused by a novel coronavirus (trial version 7) [2020]184, 2020-3-4. Available at: http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1989/files/ce3e6945832a438eaae415350a8ce964.pdf. AccessedGoogle Scholar As pneumonia progresses there are bilateral and multiple ground-glass images and infiltrates with pulmonary consolidation. These changes are accompanied by a normal or decreased peripheral white blood count with a reduction in lymphocytes. Current test kits use reverse transcriptase-polymerase chain reaction (RT-PCR) from a nasopharyngeal and oral swab. A lower respiratory tract sample such as expectorated sputum, tracheal aspirate, or bronchoalveolar lavage can be used in intubated patients.19National Health Commission of the People's Republic of China. Diagnosis and treatment protocols of pneumonia caused by a novel coronavirus (trial version 7) [2020]184, 2020-3-4. Available at: http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1989/files/ce3e6945832a438eaae415350a8ce964.pdf. AccessedGoogle Scholar Testing is recommended in all patients with signs or symptoms of infection. Geographic areas with high infection rates such as South Korea offer testing to all residents, and others test those who report contact with a known infected person. Postinfection testing is done routinely in some countries as asymptomatic individuals who recovered from a known infection can still carry and transmit the virus. All healthcare workers should be familiar with the recommendations for RT-PCR testing in their geographic region.Table 1Diagnostic Criteria for Novel Coronavirus Pneumonia Used in the People's Republic of China*General Office of the National Health Commission. Diagnosis and treatment protocols of pneumonia caused by a novel coronavirus (trial version 7), March 4, 2020.Epidemiological HistoryClinical Manifestations and CT ScanEtiology and Serology1.A history of travel to or residence in Wuhan, China, surrounding areas, or other regions with reported cases within 14 d before symptom onset2.History of contact with COVID-19–infected persons (positive nucleic acid test) within 14 d before symptom onset3.History of contact with patients who have fever and respiratory symptoms from Wuhan, surrounding areas, or other regions with reported cases within 14 d before symptom onset4.Cluster onset: 2 or more cases of fever and/or respiratory symptoms in small area such as home, office, school, or class, etc, within 2 weeks1.Fever and/or respiratory symptoms2.CT shows multiple small, patchy shadows and interstitial changes in the early stage, which is obvious in the peripheral lung field, and then develops multiple ground-glass shadows and infiltrates in bilateral lungs. In severe cases, lung consolidation may occur.3.The total number of white blood cells is normal or decreased in the early stage of onset, and the lymphocyte count is reduced.1.Positive RT-PCR test result for COVID-19 nucleic acid2.Viral gene sequencing: highly homologous to COVID-193.COVID-19–specific IgM is positive after 3-5 d of onset, and IgG antibodies in the recovery phase are 4 times or more higher than that in the acute phase.Suspected case1.One of the 3 epidemiological histories and 2 of the clinical manifestations2.Those with no clear epidemiological history but meet 3 of the clinical manifestationsConfirmed caseSuspected case + etiology or serological evidenceAbbreviations: COVID-19, coronavirus disease 2019; CT, computed tomography; IgG, immunoglobulin G; IgM, immunoglobulin M; RT-PCR, reverse transcriptase-polymerase chain reaction. General Office of the National Health Commission. Diagnosis and treatment protocols of pneumonia caused by a novel coronavirus (trial version 7), March 4, 2020. Open table in a new tab Abbreviations: COVID-19, coronavirus disease 2019; CT, computed tomography; IgG, immunoglobulin G; IgM, immunoglobulin M; RT-PCR, reverse transcriptase-polymerase chain reaction. The inability to obtain deep respiratory secretions or an inadequate nasopharyngeal swab for screening can result in a high false-negative rate of nucleic acid detection and difficulty in diagnosis and excluding COVID-19 infection from other types of respiratory infections. Serologic detection of specific immunoglobulin M antibodies is possible at 3 to 5 days after exposure. In the recovery period immunoglobulin G antibody titers can be 4 times or higher than that of the acute phase.19National Health Commission of the People's Republic of China. Diagnosis and treatment protocols of pneumonia caused by a novel coronavirus (trial version 7) [2020]184, 2020-3-4. Available at: http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1989/files/ce3e6945832a438eaae415350a8ce964.pdf. AccessedGoogle Scholar The authors present an approach for infection control for all healthcare workers and patients in preoperative areas. The resulting protocol is designed to identify all possible infected individuals because the crowded conditions in the pre- and postoperative care areas can facilitate viral transmission. The approach therefore aims to minimize or prevent transmission of COVID-19 among patient visitors and healthcare providers. The approach considers current evidence about methods of transmission and the consequences of infection in medically compromised patients. The authors have applied their practical experience from the management of patients during the COVID-19 epidemic in the People's Republic of China. The number of visitors and distance between beds in the preoperative areas should be based on current recommendations made by the Centers for Disease Control and Prevention for social distancing. The latter is defined as reducing the number of people in common areas and trying to maintain a distance (approximately 6 feet) between individuals when possible.20CDC. Preventing COVID-19 spread in communities. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/index.html.Google Scholar All healthcare providers and visitors should practice handwashing when entering, touching, and leaving the pre- and postoperative areas of care. The authors’ approach uses a protocol in the perioperative care areas that segregates patients into 3 simple and distinct groups based on the risk of transmission (Fig 1). Class I patients are those who have been shown to be negative for novel coronavirus pneumonia after screening with RT-PCR, symptoms, laboratory examinations, and imaging. Grade 1 protection is recommended and includes: (1) disposable surgical cap and surgical garments; (2) disposable gloves; (3) surgical mask; and (4) protective goggles with sterilized surgical gowns during tracheal intubation. Class II patients have negative screening tests but fever or lung imaging suggestive of COVID-19 changes. These patients are considered potentially infective. Grade 2 protection is recommended for healthcare providers and includes: (1) disposable surgical cap and disposable impermeable surgical gown (isolation gown); (2) protective goggles or headshield, disposable gloves; (3) medical surgical mask and medical N95 mask; and (4) disposable shoe covers. Class III patients are (1) those who need emergency surgery prior to screening for novel coronavirus pneumonia or (2) suspected or confirmed cases of novel coronavirus pneumonia who require emergency surgery and cannot be transferred to a designated COVID-19 hospital. Grade 3 protection is recommended and includes: (1) disposable surgical cap, scrubs, and disposable impermeable surgical gown (isolation gown); (2) protective goggles and headshield, double-layer disposable latex gloves; (3) medical N95 masks; a positive pressure headgear is recommended for tracheal intubation; and (4) disposable boot cover. Anesthesia staff should try to review the history, laboratory results, and imaging before engaging in care, including intubation or resuscitation to determine the degree of protection needed. Pre- and postoperative areas and the operating room are busy care sites. All these sites require healthcare providers from a number of different specialties. This leads to a greater amount of human traffic through these care sites and can result in a greater than average number of potentially exposed personnel owing to cross-contamination. The latter can lead to epidemic infection in the hospital. The authors therefore recommend that surgeons, anesthesiologists, and infectious disease experts form a cohesive team to conduct the 3-level evaluation system previously described. The current best practices used in the People's Republic of China consist of the 7 diagnostic criteria (epidemiologic history, cluster incidence, fever, respiratory symptoms, complete blood count, nucleic acid test, and/or serologic antibody test) (Fig 2). Surgeons are the first-line barrier against nosocomial COVID-19 infection by collecting a complete history including travel and completing laboratory screening tests. Anesthesiologists protect the hospital and patients by performing a preoperative evaluation with updated data from the 7 diagnostic criteria. A clearly written protocol for evaluation and management should be posted in each hospital and the corresponding care sites to assure that all care providers follow the same approach. Patients with any criteria suggestive of COVID-19 infection and those with insufficient findings or information to determine the risk of infection should be isolated and referred to an infectious disease expert. In an emergent situation with insufficient time to assess the risk of infection, patients should be treated as active cases and at the highest risk of transmission. Most hospitals in the People's Republic of China screen all elective patients for COVID-19 prior to surgery. 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