key: cord-0854596-5orfs2wv
authors: Shaylor, Ruth; Verenkin, Vladimir; Matot, Idit
title: Anesthesia for Patients Undergoing Anesthesia for Elective Thoracic Surgery During the COVID-19 Pandemic: A Consensus Statement from the Israeli Society of Anesthesiologists for Patients Undergoing Anesthesia for Elective Thoracic Surgery During the COVID-19 Pandemic
date: 2020-07-21
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.07.049
sha: 51e2f363f33688c6122698aab2cc8e334b54f41a
doc_id: 854596
cord_uid: 5orfs2wv

Anesthesia for thoracic surgery requires specialist intervention in order to provide adequate operating conditions and one-lung ventilation. The pandemic caused by severe acute respiratory syndrome-related coronavirus-2 (SARS COV-2)(COVID-19) is transmitted by aerosol and droplet spread. Due to its virulence, there is a risk of transmission to healthcare workers if appropriate preventive measures are not taken. COVID-19 patients may show no clinical signs at the early stages of the disease or even remain asymptomatic for the whole course of the disease. Despite the lack of symptoms, they may be able to transfer the virus. Unfortunately, current COVID-19 testing procedures around 30% of tests are associated with a false negative result. For these reasons standard practice is to assume all patients are COVID-19 positive regardless of swab results. Here we present the recommendations produced by the Israeli Society of Anesthesiologists for use in thoracic anesthesia for elective surgery during the COVID-19 pandemic for both the general population and COVID-19 confirmed patients. The objective of these recommendations is to make changes to some routine techniques in thoracic anesthesia to augment patients' and medical staff's safety.

Unlike in most operations, aerosol-generating procedures during anesthesia for thoracic surgery are not limited to intubation and extubation but may occur throughout the operation. These include but are not limited to bronchial blocker (BB) insertion, endotracheal intubation with double-lumen tubes (DLT), and bronchoscopy which are required to provide adequate operating conditions and one-lung ventilation (OLV).

The pandemic caused by severe acute respiratory syndrome-related coronavirus-2 (SARS COV-2)(COVID-19) is transmitted by aerosol and droplet spread 1 . Due to its virulence, there is a risk of transmission to healthcare workers if appropriate preventive measures are not taken. Unfortunately, current COVID-19 testing procedures around 30% of tests are associated with a false negative result. 2 .

Moreover, the clinical presentation of coronavirus infection may be masked by previously existing respiratory conditions. A typical thoracic surgery patient may present with cough, a certain degree of shortness of breath, fever, and fatigue. The decision making regarding the risk of COVID-19 based only on history details or physical examination may be difficult in these circumstances. For these reasons standard practice is to assume all patients are COVID-19 positive regardless of swab results.

Whilst guidelines have been produced for thoracic surgery these assume that the patient is COVID-19 positive and that the patient is presenting for urgent or emergent surgey 3 4 . In Israel, elective surgery resumed on 1 St May 2020 and there is a need for a pragmatic set of recommendations that address issues specific to COVID-19, whilst allowing as normal workflow as possible.

Here we present the recommendations produced by the Israeli Society of Anesthesiologists for use in thoracic anesthesia for elective surgery during the COVID-19 pandemic for both the general population and COVID-19 confirmed patients (Table) . The objective of these recommenda-tions is to make changes to some routine techniques in thoracic anesthesia to augment patients' and medical staff's safety.

These recommendations were developed initially by two experienced thoracic anesthesiologists who conducted a MEDLINE and PubMed search relating to COVID-19 and other similar viral epidemics (SARS, Swine flu, Middle East Acute Respiratory Syndrome (MERS)). The initial set of recommendations were then sent to the heads of all the cardiothoracic anesthesiology departments in Israel for review. Once these comments were incorporated into the original document, they underwent a second round of review by the Israeli Society of Anesthesia faculty members and the final set of recommendations were agreed on. Communication was carried out via WhatsApp, email and Zoom. We received input from four out of six department heads in the first round and 15 out of 18 faculty members in the second round. These recommendations were originally published by the Israeli Society of Anesthesiologists in Hebrew on 12 May 2020.

COVID-19 patients may show no clinical signs at the early stages of the disease or even remain asymptomatic for the whole course of the disease. Despite the lack of symptoms, they may be able to transfer the virus 5-7 . One of the first studies of the SARS COV 2 transmission suggests that about 44% of secondary transmission could have been caused by asymptomatic carriers 5 .

Israeli Ministry of Health reports the number of 20% of individuals tested positive for COVID-RT-PCR screening for SARS-COV-2 should be performed for all patients up to 72 hours before presenting for thoracic surgery. The usual sampling sites are nasopharynx and posterior oropharynx, lower airway tract material can be collected as well. However false-negative results are reported and the sensitivity of a single nasopharyngeal swab can be as low as 30-60% 9 . The sensitivity can be improved by repeating the test or collecting a sample from lower airways 9 .

A new emerging serology testing for antibodies for SARS-COV-2 may provide an additional tool in patients with high clinical suspicion for coronavirus infection and negative PCR results.

Some of these test systems are designed as point-of-care and are potentially able to detect the antibodies in the patient's plasma or even whole blood samples in 15 minutes. Whilst these tests are becoming more readily available, their accuracy and specificity are yet to be determined 10 .

Interestingly in contrast to laboratory testing the sensitivity of radiological examination for detection of coronavirus disease may be higher 2 . Computed tomography (CT) done in symptomatic patients with suspected COVID-19 had been shown to detect specific patterns of viral pneumonia in 97% of patients 9 . Another Chinese study reports 67% of asymptomatic patients have specific findings associated with coronavirus pneumonia on a CT scan 11 . If a recent CT scan is available it can be reviewed with a focus on viral pneumonia patterns.

Surgery for known or suspected thoracic malignancies is considered to be expedited rather than urgent or immediate surgeries. 12 These operations should be performed promptly however all scheduling should take into account the need for COVID-19 screening a minimum of 72 hours before surgery. Emergent surgery for life-threatening conditions or those who will suffer serious deterioration in their clinical condition if surgery is postponed should not be delayed for COVID-19 screening.

 SARS COV-2 RT-PCR for all patients up to 72 hours before presenting for thoracic surgery, including surgeries for known or suspected malignancy Most of the published guidelines recommend a minimum of head cover, goggles or face shield, N95 mask or equivalent, gown, and double gloves for a health care provider involved in aerosolgenerating procedures. In addition, we recommend all team members to wear N95 masks or equivalent throughout the operation as aerosol generation in these procedures is not limited to intubation and extubation, but may include multiple bronchoscopies, equipment repositioning and surgical manipulation of airways resulting in air leaks and spillage of biological material.

To conserve supply, some items of reusable PPE such as face shields and some types of N95 masks should be cleaned appropriately between patients. If PPE is to be reused between patients then there should be local policies as to which items are to be reused, how and when they are to be cleaned, and how often they should be changed.

Care should be taken when donning and doffing PPE to avoid accidental self-contamination. The use of an observer to assist in proper donning and doffing may be considered.

 Standard PPE to be worn by healthcare providers involved in aerosol-generating procedures or any team members withing two meters of the aerosol-generating procedure. As stated previously thoracic surgery includes multiple aerosol-generating procedures throughout the operation. OR personnel should be kept to a minimum. Healthcare providers assigned to thoracic surgery cases should not be simultaneously assigned to other operating rooms or asked to provide breaks to prevent the risk of cross-contamination.

Where possible all thoracic surgery should be performed in an OR that has a negative pressure system If a negative pressure room is not available the surgery can be performed in an OR with a standardized air exchange ventilation. The doors of the room must be kept closed to provide the optimal air exchange rates 3 .

 Keep OR personnel to a minimum  Healthcare providers assigned to the thoracic OR should not be asked to work in other ORs during thoracic surgery  Where possible use a negative pressure OR.

There are multiple published guidelines for anesthesia induction and intubation in COVID-19 suspected patients 9 14-19 . Their key concepts may be applicable for any patient undergoing thorac-ic surgery during the coronavirus pandemic. These recommendations include high-quality preoxygenation, rapid sequence induction with avoidance of mask ventilation, and the use of video laryngoscopy for intubation 20 . The use of a Plexiglas box or plastic sheeting to reduce aerosol spread during intubation has also been described 21 

When choosing the appropriate equipment for lung separation for thoracic surgery the same key concepts of prevention of aerosol formation, biological material spillage, and decreasing exposure apply. The final decision of which piece of equipment is most suitable for a specific patient to achieve OLV must be made on a patient-specific basis. Neither DLT nor BB has been found to be superior in the quality of lung separation. However, two differences were noticed in metaanalyses of comparison data which may support the DLT as a primary choice:

1. Intubation and positioning of a left DLT were found to be faster and easier compared to different types of BB 23 .

2. BB compared with a left DLT were more likely to require repositioning and bronchoscopy during surgery 24 .

If difficult intubation is suspected airway management plan should focus on a device with the highest possible chance of first-attempt success. Stepwise approach with a selection of different types of airway equipment and mask ventilation between the attempts is not recommended as it may lead to significant spillage of biologic material. Once the airway is secured with an endotracheal tube BB should be considered for lung isolation instead of re-intubation attempt with DLT.

The latter maneuver performed with or without the usage of tube exchanging catheters is associated with a high failure rate and may also worsen the exposure to airway secretions 25 . Even though a patient under general anesthesia with muscle paralysis is better able to tolerate bronchoscopy and the risk of coughing is minimal the possibility of aerosolization and spillage of biological material remains significant. A number of actions can be applied to prevent this and to shorten the procedure time. As such were possible the number insertions and removals of the bronchoscope should be kept to a minimum. Similarly, single-use bronchoscopes are preferable as they can be disposed of immediately rather requiring resterilization, thus reducing the chance of accidental spillage of viral particles during transport 3 4 . If disposable bronchoscopes are not available SARS-COV-2 on multipurpose bronchoscopes is effectively eliminated by routine sterilization protocols for endoscopic equipment 31 .

 Use a disposable single-use bronchoscope in preference to multiuse bronchoscopes  Optic bronchoscopes with an eyepiece rather than a video screen should be used only as a last resort  Preoxygenate with 100% O2 ventilation for several minutes and ensure the anesthetic depth is sufficient to prevent coughing. Nerve stimulators may be used for neuromuscular block monitoring.  After surgery, a disposable scope can be discarded.

 A regular bronchoscope needs to be cleaned from secretions, the working channel flushed with water, and then to be put in a closed container and sent for processing according to hospital policy.

There are very few published recommendations for extubation in patients with suspected COVID-19 undergoing surgery. Emergence from anesthesia brings back protective airway reflexes which may cause retching, salivation, or coughing. DLTs have a larger external diameter than regular endotracheal tubes. The larger areas of contact with the airway is reported to cause more coughing than with a regular ETT 33 .

Some of the current guidelines recommend transferring an intubated patient to a single occupancy negative pressure room for emergence and extubation 3 . Due to significant logistical difficulties such as the availability of negative pressure rooms and the need for nursing staff trained in the management of patients in the immediate perioperative period this recommendation is reserved for confirmed COVID-19 patients or those requiring post-operative intensive (ICU) or high dependency (HDU) care.

For most routine cases in thoracic surgery, a more practical approach for extubation may be feasible. If a patient meets the usual criteria for extubation including a return of consciousness, spontaneous ventilation, and adequate muscle strength, then extubation can be done in OR. Oral and pharyngeal suction should be performed prior to the reversal of neuromuscular blockade. A major concern is to prevent coughing and/or a need for mask ventilation. Intravenous lidocaine, propofol, opioids, or dexmedetomidine may be given to attenuate cough reflex, yet these agents may slow down the emergence and delay extubation and so should be timed appropriately [33] [34] [35] .

One study from Canada described the exchange of a DLT for a supraglottic airway device at the end of surgery. For spontaneously breathing patients a significant reduction in coughing on emergence and extubation was reported 33 . Another method reported to prevent an excessive spillage of secretions on extubation is to cover the head and torso of a patient with a plastic transparent sheet 36 . PPE with airborne protection capabilities should be worn by any staff member in the room at the time of extubation. Following extubation, a Hudson mask should immediately be applied to the patient. This decreased the risk of hypoxia and if there is any coughing, aerosol, and viral particles will be trapped in the mask. Management of these complications frequently includes drug administration by inhalation, physical therapy for assisted cough and airway drainage, administration of a CPAP or other noninvasive ventilatory support measures. Due to increased aerosolization during these procedures, early transfer of a patient from a common PACU to an HDU or ICU with less occupancy may be considered. If the treatments are delivered in PACU then the patient's bed should be moved to a distance from other patients and healthcare staff treating the patient should wear airborne level PPE.

If the patient requires reintubation in the PACU then the same precautions should be taken as for intubation in the OR including rapid sequence intubation, PPE, and ETT confirmation by capnography in preference to auscultation.

Regional anesthesia may be effective in the prevention of postoperative respiratory complications. Thoracic epidural catheter placement should be considered if not contraindicated 38 . Erector spinae plane blocks have the advantage that they can be used in patients who are anticoagulated when epidural or paravertebral anesthesia is contraindicated. However, their effect on postoperative respiratory function is not clear 39 .

Management of chest drains after surgery may also require adjustments. Although the presence of SARS COV 2 in the pleural fluid has not been described the above concepts of infection pre-cautions may be applied in a suspected or confirmed COVID-19 patient. If a significant air leak is noted in an underwater seal system this may lead to contamination of the patient's surroundings. The successful use of a bacterial filter connected to an underwater seal system has been described 40 41 .

 Patients should be placed in an area with adequate monitoring to detect post-operative respiratory complications  Healthcare workers should wear adequate PPE to protect against aerosol droplets  Epidural or Erector spinae anesthesia are the preferred method for post-operative pain control  Consider applying an appropriate filter to a chest drain with a large air leak.

The current COVID-19 pandemic is providing additional challenges for an already challenging group of patients. As lockdowns and restrictions begin to ease the number of patients for urgent and elective surgery with add to these issues. However, with suitable precautions and planning anesthesia can be safely provided to thoracic surgery patients without endangering the healthcare workers looking after them. Here we have given a comprehensive set of recommendations for the management of confirmed or suspected COVID-19 patients presenting for thoracic surgery for the entire perioperative period from preoperative assessment to post-operative pain control. BBbronchial blocker; COVID-19 -severe acute respiratory syndrome-related coronavirus-2; CT -Computerized tomography; DLTdouble lumen tube; ETTendotracheal tube; HDUhigh dependency unit; HMEheat and moisture exchanger; ICUintensive care unit; O2 -Oxygen; OLVone lung ventilation; OR -operating room; PPEpersonal protective equipment;

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

COVID-19 may transmit through aerosol

Diagnostic performance between CT and initial real-time RT-PCR for clinically suspected 2019 coronavirus disease (COVID-19) patients outside Wuhan

Thoracic Anesthesia of Patients with Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the EACTA Thoracic Subspecialty Committee

Management of the airway and lung isolation for thoracic surgery during the COVID-19 pandemic

Temporal dynamics in viral shedding and transmissibility of COVID-19

Presumed Asymptomatic Carrier Transmission of COVID-19

Virological assessment of hospitalized patients with COVID-2019

Negative test: The Chance you are Still Positive and What to Do: MAKO

COVID-19 Infection: Implications for Perioperative and Critical Care Physicians

Role of serology in the COVID-19 pandemic

Clinical outcome of 55 asymptomatic cases at the time of hospital admission infected with SARS-Coronavirus-2 in Shenzhen

The NCEPOD Classification of Intervention

Summarizing societal guidelines regarding bronchoscopy during the COVID-19 pandemic

Anesthetic Management of Patients with COVID 19 Infections during Emergency Procedures

Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists

Recommendations for Endotracheal Intubation of COVID-19 Patients

Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel

Pediatric Airway Management in COVID-19 patients -Consensus Guidelines from the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society

Anesthesia Considerations and Infection Precautions for Trauma and Acute Care Cases During the COVID-19 Pandemic

Airway Management: SIAARTI Airway Management Research Group

Thinking Outside the Box.: A Low-cost and Pragmatic Alternative to Aerosol Boxes for Endotracheal Intubation of COVID-19 Patients

Chinese Society of Anesthesiology Expert Consensus on Anesthetic Management of Cardiac Surgical Patients With Suspected or Confirmed Coronavirus Disease

A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes

Review of difficult airway management in thoracic surgery

A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery

The use of three-dimensional printing and virtual reality to develop a personalised airway plan in a 7.5-year-old child: A case report

Three-dimensional printing as an aid to airway evaluation after tracheotomy in a patient with laryngeal carcinoma

Three-dimensional printing technology: An aid for preoperative airway evaluation in patient with situs inversus totalis

Printed three-dimensional airway model assists planning of single-lung ventilation in a small child

The Use of Bronchoscopy during the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report

Airborne precautions recommended in Wuhan, China for bedside fiberoptic bronchoscopy examination of patients with COVID-19

Replacing a double-lumen tube with a single-lumen tube or a laryngeal mask airway device to reduce coughing at emergence after thoracic surgery: a randomized controlled single-blind trial

Single-dose dexmedetomidine attenuates airway and circulatory reflexes during extubation

Optimal effect-site concentration of remifentanil for preventing cough during removal of the double-lumen endotracheal tube from sevoflurane-remifentanil anesthesia: A prospective clinical trial

Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19

Intensive care in thoracic oncology

Pain management strategies for thoracotomy and thoracic pain syndromes. Seminars in cardiothoracic and vascular anesthesia

Fascial plane blocks in thoracic surgery: a new era or plain painful?

A pleural vacuum relief device for pleural drain unit use in the hyperbaric environment. Diving and hyperbaric medicine

Creating a COVID-19 safe chest tube drainage system 2020