key: cord-0955369-9itntd5u authors: Shoman, Bassam; Omar, Amr Salah; Alkhulaifi, Abdulaziz; Carr, Cornelia; Sudarsanan, Suraj; Abouelnaga, Sameh; Ewila, Hesham title: Perioperative management of COVID 19 patients undergoing coronary artery bypass surgery date: 2020-09-07 journal: J Clin Anesth DOI: 10.1016/j.jclinane.2020.110037 sha: ffe9b90b7ddea5d40928d2c02e4467f6c34f5d18 doc_id: 955369 cord_uid: 9itntd5u • COVID-19 represents a major challenge for healthcare systems globally and regionally. • The complexity of the disease requires certain considerations when surgical intervention is imminent. • Worsening of the patients’ clinical condition after cardiac surgery because of the association with COVID-19 may not be encountered. • Health care providers attending to the patients might not endure cross-infection if strict protocol is followed. Surgery. The pandemic caused by the coronavirus disease 2019 (COVID-19) placed the health care system worldwide under great pressure. Certain facilities were forced to postpone elective surgical procedures when the severity of the pandemic increased. (1) The high contiguity of COVID-19 placed the cardiac surgery societies in a position to release guiding documents aiming at practitioner's exposure risk reduction and adequate resources allocation. We are reporting three COVID-19 positive cases, without respiratory symptoms, that were diagnosed to have critical coronary artery disease underwent urgent coronary surgery to highlight the key points in their perioperative management. The project was by the Hamad medical corporation center, (IRB MRC 04-20-586). The complexity in the decision to operate on urgent basis on patient with a recent diagnosis of COVID-19 came from the novelty of the disease and limited abilities to define its impact on cardiothoracic surgical outcome. Our experience with three such patients represents pragmatic decision to operate. The apparent respiratory system stability of these patients encouraged our team to give priority to manage their acute coronary syndrome (ACS) to limit the possible mortality and morbidity. Our institute elected to do reverse transcription polymerase chain reaction (RT-PCR) from nasopharyngeal swab test for all patients presenting with ACS. Patients were considered to be COVID positive (unless proved otherwise by testing) and practitioners coming in contact with such patients used personal protective equipment (PPE). It is imperative that ACS should be managed without waiting for COVID-19 test results. We designated one operating room in our facility to receive COVID-19 positive. We prepared a flow chart for team guidance (Figure 1 ). In our three patients, anesthesia induction was carried out after 5 minutes facemask pre-oxygenation, by rapid sequence intubation (RSI) technique. We asked the ICU team to receive the patient form the theatre door to minimize PPE exhaustion and to limit staff mobility in contaminated PPE. Transport was carried out with a transport ventilator and minimum team. Patel and colleagues raised the importance of minimizing ventilator circuit disconnection, reducing staff attendance and ventilator transport. (5) Safety of COVID-19 patients transport needs to be customized in each institute. We transfer positive cases to a specific unit, which has negative-pressure rooms with additional HEPA filters. Lung protective strategy, early thromboembolic prophylaxis and extubation in a protected atmosphere were followed. None of our patients exhibited early complications and were discharged from the ICU after an average of 24 hours after surgery. Elective surgery in the time of COVID-19 The Obstacle Course of Reperfusion for ST-Segment-Elevation Myocardial Infarction in the COVID-19 Pandemic BS: study design, contribution to the concepts, writing the manuscript and revising the final form. AK: critical revision, CC: patients' s enrollment; ASO: writing and manuscript revision; SS: data management and manuscript revision, HE data collection, SE data management, cases review. All authors read and approved the final manuscript. The authors declare that they have no competing interests. Not applicable.