key: cord-0698380-uif9xtvl
authors: Ortoleva, Jamel
title: Anesthetic Considerations for Recovered COVID-19 Patients
date: 2020-10-22
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.10.032
sha: b6bcca8d62ecbf825f3d8a62b19176a3d94186f5
doc_id: 698380
cord_uid: uif9xtvl

nan

The novel coronavirus infectious disease has infected over 38 million people worldwide and resulted in over one million deaths. 1 As of October 14, 2020, there are over 26 million recovered patients. With more and more patients being considered "COVID-19 recovered", anesthesiologists must be prepared to treat and manage this emerging, poorly understood, patient population for elective and emergent surgery. Multiple considerations exist for anesthesiologists including residual pulmonary dysfunction, lingering sequelae of arterial and venous embolic phenomena with associated anti-coagulation, myocardial dysfunction, adrenal insufficiency from corticosteroid courses, neurologic manifestations, and residual neuromuscular weakness in the subset of critically ill patients. An awareness of these issues is paramount for anesthesiologists caring for this growing patient population.

The most common severe manifestation of COVID-19 is respiratory failure due to acute respiratory distress syndrome. Patients suffer from a spectrum of severity that includes requiring nasal cannula supplemental oxygen up to and including the need for extracorporeal membrane oxygenation support (ECMO) and even lung transplantation. [2] [3] [4] Preliminary reports of patients recovering from COVID-19 find residual shortness of breath and deranged pulmonary function tests suggestive of restrictive lung disease. [5] [6] [7] In the case of patients that continue to be symptomatic and polymerase chain reaction negative, the most reasonable approach would be to delay elective surgery until resolution of symptoms. If surgery is time sensitive but not emergent (such as in malignancy), it is reasonable to obtain pulmonary function tests to classify residual lung pathology in order to guide intraoperative and potentially post-operative ventilator management. In the case of an emergency, then surgery must proceed, and characterization and treatment of pulmonary pathology will need to occur intraoperatively. Note that COVID-19 may also have cardiac involvement and that shortness of breath or dyspnea on exertion could be due to myocardial dysfunction. In patients with restrictive lung disease, ventilation management can be challenging; lower tidal volumes and more modest positive end-expiratory pressure is a reasonable approach in order to avoid over distention of viable lung tissue. 8 Throughout the spectrum of disease, COVID-19 is known to result in a hypercoagulable state with a high risk of arterial and venous thromboembolic phenomena. 9, 10 In the largest study to date, hospitalized, non-critically ill patients with COVID-19 were found to have an 11.5% thrombosis rate while intensive care unit patients suffered a 29.4% thrombosis rate. 9 This is an important consideration in patients presenting for surgery given the potential for difficult with vascular access due to thrombosis, as well as the attendant effects of outpatient anticoagulation on hemostasis in emergency cases. Finally, in the case of arterial embolic phenomena to vital organs such as the brain, hemorrhagic conversion may be a concern with heparinization for procedures requiring cardiopulmonary bypass, or those involving the administration of tissue plasminogen activator for clot lysis.

Literature on the myocardial effects of COVID-19 is expanding. Magnetic resonance imaging (MRI) has found abnormalities in hospitalized and healthy recovering patients. 11, 12 Additionally, stress cardiomyopathy may be more common during the pandemic, though a direct pathophysiologic relationship to SARS-CoV-2 is not casual. 13 Clinicians should have a high index of suspicion for residual cardiac involvement in hemodynamically compromised patients presenting for surgery if other causes for hypotension are ruled out.

Multiple studies on the use of corticosteroids for COVID-19 associated acute respiratory distress syndrome (ARDS) have suggested a mortality benefit. 14-16 Doses of corticosteroids ranged from 50mg hydrocortisone every 6 hours to 20mg dexamethasone per day. Courses were typically a minimum of seven days. In referencing the American society of Anesthesiologists guideline document, patients undergoing a short course of steroids may in fact not require stress dose steroids. 17 However, these guidelines suggest that a dose of 20mg of prednisone per day for three or more weeks may be sufficient to cause hypothalamicpituitary adrenal axis suppression. In the case of the 6mg or 20mg daily dosing of dexamethasone, this is roughly 40mg or 130mg daily of prednisone, respectively. Though not three weeks in duration, this dosing is significant and may result in adrenal suppression in patients anesthetized for major surgery, or those undergoing surgery in extremis. Due to a high likelihood of receiving steroid treatment, clinicians should consider the use of stress dose corticosteroids (100mg of hydrocortisone followed by 50mg every six hours) in patients recovered from COVID-19 if other, more common, causes of persistent hypotension are ruled out. 17 Neurologic manifestations related to COVID-19 including stroke, intracranial hemorrhage, and critical illness myopathy related to prolonged intubation and immobility are important considerations in recovered COVID-19 patients. [18] [19] [20] In patients presenting for surgery after long intensive care unit stays, avoiding the use of succinylcholine may be prudent to reduce the risk of rhabdomyolysis and hyperkalemia. 21 As stated earlier, patients with covid-19 may suffer ischemic or hemorrhagic intracranial pathology with the possibility of further intracranial bleeding with the administration of anticoagulants. A meticulous review of prior central nervous system imaging should be undertaken before procedures that necessitate anticoagulation or thrombolytic therapy in order to minimize the risk of intracranial hemorrhage. Finally, many patients recovering from COVID-19 may suffer from post-traumatic stress disorder related to prolonged hospitalization; acknowledging this and discussing what concerns patients may have related to procedures performed by anesthesiologists or proceduralists is crucial to assuage anxiety.

While COVID-19 remains an entity undergoing active research, it is of the utmost importance to recognize that patients recovered or recovering from it represent an even greater unknown.

Virtually every anesthesiologist will need to care for this growing population, and thus an understanding of anesthesia relevant issues is necessary to deliver effective care. Large, ideally prospective, studies are necessary to discover the anesthetic management challenges in these patients. Anesthesiologists must take an active role in the surgical care of the COVID-19 recovered to ensure the best possible outcomes for this complex patient population.

Clinical Characteristics of Coronavirus Disease 2019 in China

Covid-19 in Critically Ill Patients in the Seattle Region -Case Series

Lung transplantation for COVID-19-associated acute respiratory distress syndrome in a PCR-positive patient

Impact of coronavirus disease 2019 on pulmonary function in early convalescence phase

Follow-up study of the pulmonary function and related physiological characteristics of COVID-19 survivors three months after recovery

Pulmonary function in patients surviving to COVID-19 pneumonia

Ventilatory support and mechanical properties of the fibrotic lung acting as a "squishy ball

Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System

Thrombosis and coagulopathy in COVID-19 patients requiring extracorporeal membrane oxygenation

Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection

Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection

Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic

Dexamethasone in Hospitalized Patients with Covid-19 -Preliminary Report

Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19: The CoDEX Randomized Clinical Trial

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

Perioperative Steroid Management

Catastrophic Intracranial Hemorrhage in Two Critically Ill Patients with COVID-19

Neurologic Features in Severe SARS-CoV-2 Infection

Critical illness myopathy after COVID-19

Succinylcholine-induced Hyperkalemia in Acquired Pathologic States