key: cord-0056437-2rt8dff1 authors: Guarracino, Fabio; Shernan, Stanton K.; Tahan, Mohamed El; Bertini, Pietro; Stone, Marc E.; Kachulis, Bessie; Paternoster, Gianluca; Mukherjee, Chirojit; Wouters, Patrick; Rex, Steffen title: EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients with Suspected or Confirmed COVID-19 Infection: An Expert Consensus from the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists with the endorsement from the Chinese Society of Cardiothoracic and Vascular Anesthesiology date: 2021-02-17 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2021.02.039 sha: d061aa605e3f13b888a7aa739cfd5da5a65140ea doc_id: 56437 cord_uid: 2rt8dff1 The European Association of Cardiothoracic Anaesthesiology (EACTA) and the Society of Cardiovascular Anesthesia (SCA) aimed to create joint recommendations for the perioperative management of patients with suspected or proven SARS-CoV-2 infection undergoing cardiac surgery or invasive cardiac procedures. To produce appropriate recommendations, we combined the evidence from the literature review, re-evaluating the clinical experience of routine cardiac surgery in similar cases during the Middle East Respiratory Syndrome (MERS-CoV) outbreak and the current pandemic with suspected COVID-19 patients, and the expert opinions through broad discussions within EACTA and SCA. We took into consideration the balance between established procedures and the feasibility during the present outbreak. We represent an agreement between the European and United States practices in managing patients during the COVID-19 pandemic. The recommendations take into consideration a broad spectrum of issues with a focus on preoperative testing, safety concerns, overall approaches to general and specific aspects of preparation for anesthesia, airway management, transesophageal echocardiography, perioperative ventilation, coagulation, and hemodynamic control and postoperative care. As the COVID-19 pandemic is spreading, it will continue to represent a challenge for the worldwide anesthesiology community. To allow these recommendations to be updated as long as possible, we provided weblinks to international public and academic sources providing timely updated data. Our document should be the basis of future Task Forces to develop a more comprehensive consensus considering new evidence uncovered during the COVID-19 pandemic. The recommendations take into consideration a broad spectrum of issues with a focus on preoperative testing, safety concerns, overall approaches to general and specific aspects of preparation for anesthesia, airway management, transesophageal echocardiography, perioperative ventilation, coagulation, and hemodynamic control and postoperative care. As the COVID-19 pandemic is spreading, it will continue to represent a challenge for the worldwide anesthesiology community. To allow these recommendations to be updated as long as possible, we provided weblinks to international public and academic sources providing timely updated data. Our document should be the basis of future Task Forces to develop a more comprehensive consensus considering new evidence uncovered during the COVID-19 pandemic. List of Abbreviations ABG Arterial blood gases ABS airway breathing system ACT Activated clotting time AGP Aerosol generating procedures AGS airway generation system ARB angiotensin II receptors blockers ASA American Society of Anesthesiology BNP brain natriuretic peptides CPB cardiopulmonary bypass COSIE COronavirus Safety during Intubation and Extubation COVID- 19 Coronavirus The principal methodologies to produce our recommendations include expert opinions through broad discussions within EACTA and SCA, re-evaluating the clinical experience of routine cardiac surgery in similar cases during the Middle East Respiratory Syndrome situation very fluid, we aimed to avoid this document being outdated in a short period by providing web links to the public sources so that the information herein provided could remain "live" for the anesthesiology community long as the sources were updated. A complete list of the web links is provided in Supplemental Table 1 . We realize that there are important variations in the healthcare system structure between European and US centers. Thus, the authors present an agreement between both the European and US practice in managing patients during the COVID-19 pandemic, and these recommendations were considered best practices as of the completion of this manuscript's writing on February 6, 2021. The group considered a broad spectrum of issues regarding cardiac anesthesia in patients who are suspected or diagnosed to have COVID-19 infection and decided to focus on overall approaches to general and specific aspects ( Table 1 ) of preparation for cardiac anesthesia, airway management, perioperative ventilation, coagulation, and hemodynamic control and postoperative intensive care. To produce appropriate recommendations, we combined the evidence from the literature and expert opinions. The recommendations consider safety concerns for patients and healthcare providers, the balance between established procedures, and the feasibility during the present outbreak. As our goal was to make this preliminary consensus rapidly available to all cardiac surgical teams, we acknowledge the adopted methodology's limitations. Disclaimer: The information set forth herein is not intended to replace the considered judgment of a licensed professional with respect to patients, procedures, or practices. The information found in this document may not be appropriate for all patients and neither EACTA, the SCA, nor the individual contributors make any warranty, guarantee, or other representation, express or implied, with respect to their fitness for any particular purpose. All statements that are not specifically referenced are based on expert opinion.  The Hospital organization should provide separate perioperative pathways for non-COVID-19 and COVID-19 positive patients (9) . These pathways apply also to patients transferred from other Institutions.  Every patient should be screened clinically (10)and virologically for SARS-CoV 2 infection. The current practice is to collect a specimen from the pharyngeal or nasal mucosa with a swab to confirm the virus's presence with polymerase chain reaction (PCR) quantification to reveal the viral genome. [click here].Testing should be performed as close to surgery as possible (preferably less than 48 hours) to decrease the risk that a patient becomes positive while waiting for the surgical procedure (11) .  When dealing with positive tested COVID-19 patients, hospital planning and organization should ideally consider if surgery is emergent or elective [click here].  We recommend that in cardiac patients with clinical symptoms suggestive of infection with SARS-CoV 2 (e.g., cough, fever) and a negative PCR test result, a computerized chest tomography (CT) is performed (12) .  Suppose surgery is urgent and necessary in a patient with suspected or confirmed infection, before proceeding to the operating theatre. In that case, providers should ensure that appropriate perioperative care units are notified and plans established to care for patients with known or suspected COVID safely (9) .  After a patient is transferred, the breathing circuit should be discarded.  The soda-lime canister and airway breathing system (ABS) / airway generation system (AGS) of the ventilator should be decontaminated according to the manufacturers' recommendations.  All consumables should be disposed.  All reusable materials should be sent for decontamination according to the manufacturers' recommendations.  A waiting period of 20 minutes is necessary to disinfect the operating room, all uncovered surfaces including the CPB, ABG, ACT, thrombelastography machines, TEE and CPB machines, and OR table using 3% -5% chlorine solution, or plastic covers should be exchanged. Operating Room and Equipment Management  Ideally, a dedicated COVID-19 operating room with negative pressure and >12 air cycles/hour should be used for cardiac surgery.  In rooms with positive pressure, the pressure should be set at the lowest level assuring adequate air treatment. The doors should be kept closed so that the high exchange rate of air in operating theatres limits aerosols' dispersion outside the theatre, despite the airflow directed from inwards to outwards.  During surgery, the operating room temperature level should be reduced to [18] [19] [20] degrees (13), and humidity is kept between 40 and 60% (14) . Inside the room, preferably there might be three staff including the most experienced cardiac anesthesiologist to intubate the patient's trachea; a second doctor should be present for unanticipated difficulty, and a circulating nurse or anesthesia assistant/technologist should help to administer drugs and monitor the patient.  There must be a "runner" available directly outside the room in case of need for handling any equipment or medicines.  Surgeons, perfusionists, and scrub nurses should wait outside the room until the airway has been secured, ventilation started, the TEE and esophageal temperature probe have been inserted  There should be a dedicated area outside the operating room in which the operators can safely doff the PPE, and an observer has to be present to monitor the process.  Another measure of adequate pre-oxygenation is to assess the fraction of exhaled oxygen (measured from the patient's exhaled breath) that should exceed 80%.  Intubation could be preferably performed using a video laryngoscope with a remote screen to maximize the distance from the anesthesiologist and the patient's mouth and avoid aerosol transmission (23) .  The unanticipated difficult airway should be treated similarly to ordinary cases as per institution practice or internal guidelines. We recommend the suggested approach by SIAARTI and UK joint societies (23)(24) as follows: o The first laryngoscopy attempt should be performed with an endotracheal tube pre-loaded on a stylet. o If it fails, a re-oxygenation period can be needed, which has to be applied with a low tidal volume/pressure to avoid leakage of contaminated air o If a 3 rd attempt is necessary, an early switch to a second-generation intubating supraglottic airway device should be considered (25) . Intubation through this device should be performed with a flexible (preferably disposable) endoscope, again with a separate remote screen. o No aerosol or vaporization should be used for airway topical anesthesia. o A titrated sedation with monitoring sedation depth has to be performed (23) . o Appropriate sizes of double-lumen tubes, bronchial blocker, and fiberoptic bronchoscopes should also be ready and prepared (26) . o Placement of a double-lumen tube can be the first choice for patients intubated inside the OR with no predicted airway difficulty. o Bronchial blockers are recommended as the first choice for patients who arrive in the OR while already intubated patients. o If a double-lumen tube is used, the position of the device could be confirmed with a disposable flexible bronchoscope using a swivel with a valve to maintain a better seal during the maneuver and, if possible, putting the ventilator on standby mode with pausing the gas flow to reduce the aerosolizing of contaminated air, while continuing to ventilate the other lumen (27) . An HME filter should be placed on the clamped, not ventilated lumen which is open to the air to facilitate lung collapse (26) .  A nasogastric tube can be placed if needed.  If the diagnosis of COVID-19 is not already confirmed, a deep tracheal aspirate for virology should be taken using closed suction.  Esophageal temperature and TEE probes with adequate covers should be inserted then.  The patient should remain connected to the breathing circuit as much as possible.  A closed system with an infra-glottic catheter tip should be positioned upon tracheal intubation and used for suction (28, 29) .  If discontinuation of the ventilation is needed, the ventilator should be placed in standby mode, and the endotracheal tube should be clamped. Before clamping the endotracheal tube, muscle relaxation should be confirmed such that the patient will not attempt to breathe against an occluded airway. o Some degree of hypercapnia can be permitted by adjusting the respiratory frequency (pH >7.2). o Potentially a higher PEEP may be required than that for a patient without COVID- 19 : approximately 13-15 cm H2O; a PEEP titration strategy is suggested but should be performed very cautiously so as not to cause a decrease in cardiac output in higher PEEP levels. o Patients may benefit from the application of an alveolar recruitment maneuver, and a trial is recommended; it should be kept in mind, however, that the recruitment strategy can impair the hemodynamic stability in a more extended way than in "healthy" patients  TEE should be limited to selected cases, its application is based on a risk/benefit balance.  A focused transesophageal exam using a step-by-step approach should be considered.  We recommend that the TEE probe with an adequate cover is inserted only after endotracheal intubation (32).  If not used, the TEE probe should be available in the room as it could be necessary as a subsequent step or aid during unexplained hemodynamic instability.  After the exam is carried out, the probe and machine's proper disinfection is mandatory as recommended by the manufacturers.  In the case of a suspected or diagnosed COVID-19 patient with structural heart disease amenable for a transcatheter procedure, a multidisciplinary team discussion between the cardiac anesthesiologist, surgeons, and interventional cardiologist is advocated as the majority of procedures (e.g., transcatheter aortic valve implantation/replacement (TAVI/TAVR) might not be recommended for the elderly comorbid COVID-19 patient.  If a non-intubated procedure is considered, we recommend that the patient wear a surgical mask to avoid environmental contamination and reduce the risk of contagion for health care providers who should wear full PPE. A local protocol including early mobilization, accelerated reconditioning, and early discharge planning should be developed (39) .  Multidisciplinary discussions involving cardiac anesthesiologists, surgeons, and intensivists should be considered to define the feasibility of immediate extubation of patients after surgery if that is the local practice at the center and in case of drained resources in terms of shortages of ICU beds.  In general, patients with suspected and confirmed COVID-19 diagnosis should be left intubated and ventilated after surgery, particularly those who were already intubated before surgery, patients with COVID-19 pneumonia with low PaO 2 /FiO 2 ratio, or those with an anticipated or unanticipated airway difficulty.  The patient should meet all criteria for extubation after cardiac surgery.  Extubation is an AGP; thus, two staff should stay in PPE during recovery and extubation.  It has been reported that the patients usually have excessive retained secretions, especially during the weaning phase, with increased risks for the need for reintubation (30) . Gentle suctioning through a closed suction circuit (e.g., suction through a 15-mm swivel connector or a tracheal tube with a subglottic suction port) or pausing the flow by switching the ventilator to "standby mode" should be considered before extubation without precipitating cough. An alveolar recruitment maneuver could follow that (26) .  Some drugs (e.g., dexmedetomidine, lidocaine, magnesium sulfate) can decrease the risks for coughing during and after extubation, with dexmedetomidine being the most effective pharmaceutical strategy (40) . Destination after Transferring  After completing surgery, the patient is usually transferred to a dedicated ICU for COVID-19 patients in case of a proven or suspected COVID-19 infection.  COVID-19 patients with no available dedicated ICU beds for COVID-19 could preliminarily remain in the operating room in which routine care after cardiac surgery should be provided with donning the routine PPE levels described above.  Transferring patients with COVID-19 pneumonia could be challenging due to the difficulty of maintaining the required ventilation settings as described above.  A HEPA or HME viral filter should be connected between the tracheal tube and the portable ventilator or self-inflating resuscitation bag.  Using a portable ventilator able allowing to adjust FiO 2 , tidal volume, and PEEP levels is recommended.  Otherwise, ventilation using a resuscitation bag and valve can be considered by incorporating an antiviral filter and reservoir to minimize the aerosol transmission risks.  Airway disconnections should be minimized and the tracheal tube clamped when possible.  Transferring extubated patients should follow the local regulations.  Gas flow to the surrounding area should be minimized as much as possible by using a surgical or N95 mask over the patient's mouth (41) and nose or using a Coronavirus Safety during Intubation and Extubation (COSIE) COVID-19 Aerosol Box (43) .  Patients should be transferred with a facemask with oxygen if needed (e.g., Venturi, Hudson, or nonrebreather masks with the lowest possible gas flow). Patients undergoing surgery after contracting coronavirus are at greatly increased risk of postoperative cardiovascular (myocarditis, cardiogenic shock, vasoplegic shock , acute coronary syndrome, right ventricular dysfunction/failure) (44) (45, 46) (46) . That could be associated with significant STsegment changes, increased serum levels of cardiac troponin and brain natriuretic peptides (BNP), and severe hypokinesia (47) . Elevations in troponin levels have been shown to predict mortality in patients with COVID-19 (48) .  Preoperative hemodynamic control should be considered using either pharmacological (e.g., inotropes, vasopressors, or angiotensin II) or mechanical circulatory support (e.g., veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella)  Patients with COVID-19 infection might present preoperatively with vasoplegic shock secondary to sepsis (10% to 15%) and/or disordered function of the reninangiotensin-aldosterone system (49) (45) . That should be taken into account during preoperative assessment emphasizing on conduction abnormalities, the presence of acute kidney injury, and correction of electrolyte and pH disturbances [click here].  Right ventricular dysfunction is common in COVID-19 patients, with an estimated prevalence of 25% to 50% (46) .  Preoperative optimization of right ventricular function with the possible use of inhaled nitric oxide (51) or inhaled epoprostenol or milrinone may be considered in these patients. The viral filter should be appropriately positioned to limit contamination of inhaled medication delivery systems. In-hospital cardiopulmonary resuscitation should follow the precautions provided by the American Heart Association [click here]. As the COVID-19 pandemic is spreading, it will continue to represent a challenge for the worldwide anesthesiology community, and most likely, we all will need to deal with it at some point in the future. This document provides recommendations on hospital and staff planning, safety and protection of health care providers and patients, management of transcatheter approaches, and postoperative management and after surgery care. Further, we provide focused considerations on major hemodynamic and thrombotic complications related to COVID-19. We sincerely hope that these recommendations will be of help in everyday clinical practice. 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