key: cord-0937278-4zr3gvzy
authors: Moreno‐Duarte, Ingrid; Evans, Amanda S.; Alder, Adam C.; Vernon, Madeline C.; Szmuk, Peter; Rebstock, Sarah
title: An unexpected COVID‐19 diagnosis during emergency surgery in a neonate
date: 2021-02-25
journal: Paediatr Anaesth
DOI: 10.1111/pan.14156
sha: 70fc410cb2f1389e678b8f0f85ce237f88367210
doc_id: 937278
cord_uid: 4zr3gvzy

A 4‐day‐old, 3.3 kg infant presented with suspected intestinal malrotation, necessitating emergent diagnostic laparoscopy. Intra‐operatively, the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) came back positive. This is the first case report of emergency surgery and anesthesia in a positive SARS‐CoV‐2 newborn. This report highlights a neonate with an incidental positive SARS‐CoV‐2 test, no known exposure history, negative polymerase chain reaction maternal testing, and absence of respiratory symptoms who required modified pressure control ventilation settings to adequately ventilate with the high‐efficiency particulate air filter in situ.

Coronavirus 19 (COVID-19) infection can be transmitted to neonates from birth. 1, 2 Healthcare workers in the U.S. are working with critical limitations in personal protective equipment (PPE) and testing resources. Airway management for COVID-19 poses challenges in neonatal patients and has added risk to the provider inherent in those aerosol-generating procedures. 3 Recognition of ventilatory failings and good clinical judgment is important in determining the appropriate ventilator settings in neonates. 3 We described a case of a neonate with low pretest probability for COVID-19 infection born in a high-prevalence region, found unexpectedly to have COVID-19 infection during surgery. 4

A 4-day-old, 3.3 kg infant presented with suspected intestinal malrotation, necessitating emergent diagnostic laparoscopy. The child was born at 37 4/7 weeks gestation via vaginal delivery, to a 24-year-old G2P2 Hispanic mother with no prenatal care. The mother's SARS-CoV-2 screening test was negative. The infant was formula and breastfed, roomed-in with her mother, and was discharged home at 48 hours of life. On the 3rd day of life, the infant visited the pediatrician and was otherwise at home, without sick contacts. The mother denied recent contact with infected individuals and denied any symptoms of COVID-19.

Due to the infant's young age, maternal negative testing at delivery, and no known COVID exposures during pregnancy or after birth, the infant was not categorized as a "person-under-investigation" (PUI) for COVID-19 according to institutional policy. SARS-CoV-2 testing (Biofire ® Filmarray ® Respiratory Panel) from a nasopharyngeal specimen was performed as part of presurgical screening.

We proceeded emergently to the OR with pending SARS-CoV-2 results and made a clinical decision to utilize airborne precautions perioperatively.

The anesthesia staff donned N95 masks, googles, gowns, and gloves prior to anesthesia induction. A high-efficiency particulate air (HEPA) filter (303; Vyaire) was placed in line between the patient and the anesthesia machine on the expiratory limb. After preoxygenation and intravenous induction, the patient was easily intubated under direct laryngoscopy with a cuffed endotracheal tube size 3.0. There was no significant air leak. We were able to adequately hand ventilate the patient and achieve normal tidal volumes and CO2 readings with HEPA filter in situ. The patient was placed on pressure control ventilation (PCV; inspiratory pressure of 17 mmHg, positive end expiratory pressure of 5, on a fraction of inspired oxygen of 50%). These ventilator settings were inadequate, and titration to higher inspiratory pressures was required for adequate endtidal carbon dioxide (ETCO2) and chest rise. The surgery was converted to laparotomy after initial laparoscopic evaluation showed complex duodenal atresia. can only be confirmed with repeat testing. The mother's test cannot be ruled out as a false negative result, which may occur when the concentration of the virus in the sample is below the limit of detection.

It is also possible that the infant had a false-positive test. Neither the infant nor her mother had repeat SARS-CoV-2 testing (neither PCR nor serology) after hospitalization due to lack of parental resources. 

Intrauterine transmission of SARS-COV-2 infection in a preterm infant

Sequential analysis of viral load in a neonate and her mother infected with SARS-CoV-2

Perioperative care of the newborns with CHDs in the time of COVID-19

BioFire Defense L. Biofire COVID-19 test. Instructions for use 2020 Available from