key: cord-0876171-re7yqm1c
authors: Abdou, Hossam; Tolaymat, Besher; Jinwala, Felecia; Nagarsheth, Khanjan H.
title: A Cautionary Tale of an Emergency Cerebrovascular Procedure in the COVID-19 Era
date: 2020-09-02
journal: J Vasc Surg Cases Innov Tech
DOI: 10.1016/j.jvscit.2020.08.023
sha: a5a71f3c16e8597aab9c551822f742c2ed05e68b
doc_id: 876171
cord_uid: re7yqm1c

The Coronavirus disease 2019 pandemic has impacted system processes with airway management being significantly affected. A 37-year old female diagnosed with stroke was found to have a filling defect at the origin of the right internal carotid artery. She was taken to the operating room urgently for carotid endarterectomy. The procedure was uneventful; however, she developed anaphylaxis upon extubation subsequently attributed to Sugammadex. Institutional policies and limited resources resulted in delayed reintubation. Fortunately, she did not have lasting deficits, but this highlights the potential of current policies to lead to complications and the need to improve policies to minimize harm.

The Coronavirus disease 2019 (COVID-19) pandemic has led to several systemic 2 changes in the delivery of healthcare. Some of the most pronounced changes have occurred in 3 the management of the airway. Hospitals all over the world have adopted intubation precautions 4 including minimizing staff in the room, donning appropriate personal protective equipment 5 (PPE) -typically powered air purifying respirators (PAPRs), using rapid sequence intubation 6 (RSI), and using video laryngoscopy [1] [2] [3] . Preparing equipment and drugs ahead of time and 7 developing communication plans are also being strongly encouraged 2,3 . In the United States, the 8 American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) have 9

issued guidelines that are consistent with those presented internationally 4,5 . However, these 10 adjustments, among others, are a challenge to execute and are likely not without collateral 11 damage 6 . The patient described in the following case gave her consent to the publication of this 12 case and its associated images. 13

A 37-year old female who presented to the emergency department with severe headache, 15 ataxia, left-sided weakness and 'shaking' was found to have a small frontotemporal stroke and a 16 filling defect at the origin of the right internal carotid artery. Of note, she did not exhibit 17 symptoms of COVID-19 including fever, fatigue, or cough, and she tested negative for the virus 18 insult to the brain. The procedure occurred without intra-operative complication. Upon 7 extubation, however, the patient became profoundly hypoxic and then unresponsive. She 8 developed acute angioedema with swelling of the face, mouth and oropharynx. The angioedema 9

and swelling were later attributed to a medication reaction to Sugammadex (Merck & Co., Inc, 10

Kenilworth, NJ, USA). 11

Unfortunately reintubation was complicated. Extubation protocol called for all staff to 12 leave the operating room except for the anesthetist who donned a PAPR during the procedure, 13 but this left the anesthetist without equipment or assistance when the emergency presented. In 14 fact, given that policy dictated that all other staff remain outside the room for a minimum of 21 15 minutes post extubation meant that the anesthetist was particularly isolated. Institutional policy 16 also required the use of PAPRs and video laryngoscopy during intubation and a limited supply of 17 this equipment meant that they were not immediately available. These materials were eventually 18 obtained, and she was successfully reintubated after 18 minutes. Emergent imaging revealed 19 stable infarcts with overall decreased perfusion abnormalities. Pathology of the specimen was 20 thrombus. She was discharged on post-operative day 5 to an acute rehabilitation facility with 21 persistent mild dysarthria and mild left upper extremity weakness that were present 22 preoperatively. Now 3 months post-op, she has no deficits. 23 depolarizing neuromuscular blockade from rocuronium 7 . Anaphylaxis is a known but rare 3 complication of the administration of sugammadex 8 and occurs in 0.036% of cases. When it 4 occurs urgent re-intubation is necessary. However, in the context of hospital policies 5 implemented to minimize and prevent viral transmission, this process has become more 6 challenging. Important equipment, including PAPRs and videolaryngoscopes, are at a premium 7 and are limited in availability. Additionally there has been a reduction in the number of people 8 available in the operating room at the time of induction and extubation in accordance with 9 guidelines from the Difficult Airway Society 2 . This inequity of equipment, personnel and 10 supplies can lead to potentially harmful consequences. Fortunately the patient in our case did not 11 have lasting deficits, though she required two additional days of mechanical ventilation post-12

It is also important to highlight that this complication occurred in a patient that was not 14 suspected to be COVID-19 positive. A lack of sufficient, effective, and rapid testing dictates that 15 intubation precautions need to be universal, which contributed to this adverse event. It is 16 plausible that improved testing mechanisms could have spared this patient this complication. 17

There is an urgent need for better tests and more of them. 18

Unfortunately, it is unlikely that complications such as this can be eliminated in the 19 current state of affairs. However, it is imperative that steps be taken to minimize complications 20 resulting from viral transmission prevention practices. Planning ahead and clear communication 21

are critical to achieve this goal. One practice that may be of value would be to coordinate the 22 availability of necessary limited resources. For example, a central team in charge of transporting 23 this equipment could be contacted by the circulating nurse at critical junctures such as extubation 1

where emergent intubation could be required. 2

We owe it to ourselves as healthcare workers to take the appropriate precautions in order 3 to minimize our risk of exposure to COVID-19. Nevertheless, we owe it to our patients to 4 continuously improve our policies and practices so that protecting ourselves does not result in 

Reducing droplet spread during airway manipulation: lessons from the

Efficacy and safety of sugammadex versus 1 neostigmine in reversing neuromuscular blockade in adults

Comparison 4 of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective 5 multicentre observational study