key: cord-0902316-2h8y118z
authors: Sun, Xingxing; Liu, Yong; Mei, Wei
title: Safety Considerations for Neuraxial Anaesthesia in Parturients with COVID-19
date: 2020-05-14
journal: Br J Anaesth
DOI: 10.1016/j.bja.2020.05.005
sha: e299c415caecdb4d6d1de712a0983bbb2ecc1833
doc_id: 902316
cord_uid: 2h8y118z

nan

To decide the mode of anaesthesia for parturients with COVID-19, one should evaluate neurological symptoms in addition to respiratory symptoms.

In recent clinical practice in Wuhan, China, neuraxial anaesthesia is the first and main choice in parturients with COVID-19 undergoing a Caesarean section. [2] [3] [4] [5] Other than the general benefits offered by neuraxial anaesthesia over general anaesthesia, an additional advantage of neuraxial anaesthesia for Caesarean delivery in parturients with COVID-19 is avoidance of airway manipulation and patient coughing during intubation and extubation, thus reducing the risk of aerosol generation and dispersion of viral particles. From January 1, 2020 to February 9, 2020, 36

Caesarean sections were performed uneventfully in Tongji Hospital, a university-affiliated general hospital in Wuhan with COVID-19 confirmed in 11 parturients (31%). In total, 31 parturients (86%) received neuraxial anaesthesia and 5 (14%) received general anaesthesia. 6 Is neuraxial anaesthesia safe for COVID-19 patients? Should we reconsider neuraxial anaesthesia because of reported neurological symptoms in these patients?

Angiotensin-converting enzyme 2 (ACE2) is the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); 7 it is expressed in the cell membrane of various tissues and organs including lung, small intestine, and brain. 8 ACE2 in the brain might provide a mechanism for SARS-CoV-2 to cause neurological symptoms, but the possible invasion routes of SARS-CoV-2 remain unknown. Considering the invasion routes of other coronaviruses, SARS-CoV-2 might enter the central nervous system through the olfactory bulb, bloodstream, or peripheral nerve. 9 The neurological symptoms of patients with COVID-19 can be divided into two categories: 1)

central nervous system symptoms such as headache (13.1%), dizziness (16.8%), impaired consciousness (7.5%), ataxia (0.5%), acute cerebrovascular disease (2.8%), and epilepsy (0.5%); 1 and 2) peripheral nervous system symptoms, such as hyposmia (loss of smell) (5.1%), hypogeusia (loss of taste) (5.6%), hypopsia (visual deterioration) (1.4%), and neuralgia (2.3%). 1 It is difficult to distinguish between post-dural puncture headache and headache caused by SARS-CoV-2. It is also difficult to distinguish between neuralgia caused by mechanical injury during dural puncture and neuralgia caused by SARS-CoV-2. Spinal anaesthesia could carry the risk of introducing virus from blood or tissues into the cerebrospinal fluid, which might lead to entry of the virus into the central nervous system, even though there is no direct evidence of this. When deciding on anaesthetic strategy for patients with COVID-19, we think that one should consider the possible deleterious effects on the nervous system by neuraxial anaesthesia. For patients with apparent central or peripheral nervous system symptoms, although direct evidence is still lacking, general anaesthesia might be an acceptable alternative. However, general anaesthesia can impair the blood-brain barrier 10 , which might facilitate the invasion of SARS-CoV-2 into the central nervous system. Additional studies are needed to determine the best anaesthetic strategy for patients with COVID-19.

Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease

Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients

Emergency Caesarean delivery in a patient with confirmed coronavirus disease 2019 under spinal anaesthesia

Spinal anaesthesia for patients with coronavirus disease 2019 and possible transmission rates in anaesthetists: retrospective, single-centre, observational cohort study

Perioperative Management of Patients Infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists

A pneumonia outbreak associated with a new coronavirus of probable bat origin

Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis

Neurologic Alterations Due to Respiratory Virus Infections

Anesthesia and Surgery Impair Blood-Brain Barrier and Cognitive Function in Mice