key: cord-1033187-undi9eil authors: Uppal, V.; Sondekoppam, R. V.; Landau, R.; El‐Boghdadly, K.; Narouze, S.; Kalagara, H. K. P. title: Neuraxial anaesthesia and peripheral nerve blocks during the COVID‐19 pandemic: a literature review and practice recommendations date: 2020-05-14 journal: Anaesthesia DOI: 10.1111/anae.15105 sha: 0680431002ecb1598cb6d56c73a8fca9652e2ed6 doc_id: 1033187 cord_uid: undi9eil Coronavirus disease 2019 (COVID‐19) has had a significant impact on global healthcare services. In an attempt to limit the spread of infection and to preserve healthcare resources, one commonly used strategy has been to postpone elective surgery, whilst maintaining the provision of anaesthetic care for urgent and emergency surgery. General anaesthesia with airway intervention leads to aerosol generation, which increases the risk of COVID‐19 contamination in operating rooms and significantly exposes the healthcare teams to COVID‐19 infection during both tracheal intubation and extubation. Therefore, the provision of regional anaesthesia may be key during this pandemic, as it may reduce the need for general anaesthesia and the associated risk from aerosol‐generating procedures. However, guidelines on the safe performance of regional anaesthesia in light of the COVID‐19 pandemic are limited. The goal of this review is to provide up‐to‐date, evidence‐based recommendations or expert opinion when evidence is limited, for performing regional anaesthesia procedures in patients with suspected or confirmed COVID‐19 infection. These recommendations focus on seven specific domains including: planning of resources and staffing; modifying the clinical environment; preparing equipment, supplies and drugs; selecting appropriate personal protective equipment; providing adequate oxygen therapy; assessing for and safely performing regional anaesthesia procedures; and monitoring during the conduct of anaesthesia and post‐anaesthetic care. Implicit in these recommendations is preserving patient safety whilst protecting healthcare providers from possible exposure. The severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) pandemic has reached unprecedented proportions and has significantly impacted healthcare services and surgical volume. Some of the clinical challenges have resulted from the fact that approximately 80% of infected individuals present with no or only mild symptoms of respiratory infection and that, in the absence of universal testing, clinical screening has not allowed the reliable identification of infected patients [1] . In a recent publication, among 210 asymptomatic women admitted for labour and delivery in New York hospitals, 14% had tested positive for SARS-CoV-2, emphasising the utility of universal testing in communities with a high prevalence of coronavirus-2019 (COVID-19) infection [2] . The virus is highly infectious; the reproductive number (R 0 ), which represents the number of secondary infections resulting from an infected individual, is thought to be 2.6 (95%CI 1.5-3.5) [3] . However, a recent study suggested that the median R 0 value of COVID-19 may be as high as 5.7 [4] . In an attempt to limit the spread of infection and to preserve healthcare resources, including staffing, operating rooms and anaesthesia machines, elective surgical procedures have been postponed in many countries [5] . However, anaesthesia care is still needed for urgent and emergency surgery. Similar to previous pandemics, healthcare workers are highly vulnerable to contracting the infection. Hence, strategies to minimise exposure and the risk of disease transmission to healthcare workers or patients in the hospital is crucial. Peri-operative settings and emergency rooms are considered 'hot zones' for disease transmission, and measures to minimise exposure and transmission are vital in these areas [6] . One of the strategies to minimise exposure is to avoid aerosol-generating procedures such as airway management procedures commonly performed in the peri-operative period. General anaesthesia with airway intervention leads to aerosol generation, which exposes the healthcare team to risk of transmission of COVID-19 both during tracheal intubation and extubation [7] . The odds of transmission of acute respiratory infection during tracheal intubation to a healthcare worker are thought to be 6.6 times compared with those who are not exposed to tracheal intubation [8] . Tracheal intubation for a COVID-19-positive patient is ideally performed in a negative pressure room, which may not be available in all places or situations [9] . On the other hand, regional anaesthesia is associated with a lower risk of postoperative complications, and this becomes more important in the context of ongoing respiratory infection [10, 11] . Regional anaesthesia may be the preferred choice for providing anaesthesia care when possible, as it can provide an alternative safe anaesthetic care plan by avoiding the need for aerosol-generating procedures. Secondly, in the light of expected anaesthetic drug shortages during this pandemic, regional anaesthesia may spare the need for sedatives and hypnotics and hence is less resourceintensive compared with general anaesthesia. Despite previous respiratory pandemics such as SARS in 2003 and Middle East respiratory syndrome (MERS) in 2012, there is very little evidence-based guidance available for the practice of regional anaesthesia. An urgent need for such guidelines has been suggested by practising anaesthetists [12] . Our group recently published an interim joint statement by the American Society of Regional Anesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy for the practice of regional anaesthesia during the COVID-19 pandemic [13] . The current paper aims to provide more detailed, evidencebased practice recommendations for the safe performance of regional anaesthesia applicable to the current COVID-19 pandemic. A three-step approach was employed, which included a formal literature search followed by hand searches on individual domains, following which recommendations were generated through mutual consensus. The domains of interest were: planning of resources and staffing; modifying the clinical environment; preparing equipment, supplies and drugs; selecting appropriate personal protective equipment (PPE); providing adequate oxygen therapy; assessing for and safely performing regional anaesthesia procedures; and monitoring during the conduct of anaesthesia and post-anaesthetic care. Firstly, a formal literature search was performed for evidence on the use of regional anaesthesia during respiratory pandemics. This was conducted by an experienced librarian (DC) and included PubMed, Embase and the Cochrane Library. The searches were limited to the English language, humans and to a publication date between 1 January 2000 and 9 April 2020. The terms COVID-19 (or SARS or H1N1 or MERS); anesthesia (or anaesthesia, or anaesthetics or anesthetics); surgery; and/or operating rooms were used for the search (see online Appendix S1). This search aimed to explore all the literature pertinent to the practice of regional anaesthesia during COVID-19 or similar outbreaks. Specific populations, interventions or outcomes were not added to keep the search broad to include surgical anaesthesia and analgesia. The titles and abstracts were screened by two authors independently (VU/HK) to select all publications providing recommendations or reporting on the use of regional anaesthesia for a surgical procedure in the context of respiratory infection epidemic caused by viruses similar to SARS-CoV-2 (SARS; H1N1; MERS). Any conflicts were resolved by consensus. Backward reference searching was conducted for the selected articles to ensure any essential references were not missed. Full texts of all the selected articles were reviewed in detail, and points relevant to neuraxial and regional anaesthesia were extracted. Since the formal literature search revealed a paucity of evidence to make any conclusive recommendations, hand searches were performed by the authors to look for either clinical or laboratory evidence on the individual domains relevant to the practice of regional anaesthesia. The literature evidence was further supplemented by professional society guidelines and landmark articles important to the practice of regional anaesthesia. With the collected literature evidence as the basis, practice recommendations were derived through mutual consensus after iterative discussion among the authors. The literature search identified 987 articles. After title and abstract screening, 16 papers were selected for full-text review; among those, there was one retrospective cohort study [14] ; four case series [15] [16] [17] [18] ; four case reports [19] [20] [21] [22] ; and seven expert opinion articles [1, 12, [23] [24] [25] [26] [27] (Table 1) . Backward citation identified additional reports; however, the information relevant to regional anaesthesia was already presented in original papers in the initial search. An additional case series was identified by a co-author (RL) during the process of manuscript preparation and was included [28] . The overall quality of evidence was moderate to low, with most studies being single-centre cohort studies, case-control studies, case series or case reports. There was very little evidence available from the 17 selected publications regarding oxygen therapy, PPE or the conduct of regional nerve blocks (Fig. 1) . Recommendations on these aspects were mainly obtained based on the hand searched articles and society guidelines. The overall quality of evidence was low, and hence the strength of the recommendations is moderate to weak. The highest available level of evidence relevant to the practice of regional anaesthesia is summarised below Table 1 Summary of publications reporting on regional anaesthetic or neuraxial procedures in patients with COVID-19 infection. Altiparmak et al. [12] Letter to editor Neuraxial anaesthesia and peripheral nerve blocks should be the first choice (whenever possible) for anaesthetic management of patients with suspected COVID-19 infection. Need for a regional anaesthesia guideline in patients with COVID-19 infection. Aminnejad et al. [27] Letter to editor Debates safety of general anaesthesia vs. neuraxial anaesthesia Bauer et al. [16] Case series (n = 14) No reported neurological sequelae after neuraxial procedures in 14 obstetric patients with COVID-19 infection with varying severity of the infection. Thrombocytopenia was reported in two pregnant patients without pre-eclampsia. Suggests that the risk of causing meningitis or encephalitis is extremely low with neuraxial procedures, even in infected patients. Bauer et al. [15] Expert opinion Early labour epidural analgesia recommended. Maternal hypotension during caesarean delivery with epidural or spinal anaesthesia has not been noted. Breslin et al. [28] Case series (n = 18) Eighteen cases with neuraxial anaesthesia in obstetric patients (either using intrapartum epidural analgesia, spinal or combined spinal-epidural anaesthesia). None had contra-indications (such as thrombocytopenia or sepsis) to the neuraxial procedure, no haemodynamic instability was noted in any of the patients, and no neurological complications were observed. Chen et al. [17] Case series (n = 14) Twelve out of the 14 parturients (86%) undergoing epidural anaesthesia experienced a higher rate of intra-operative hypotension when 2% lidocaine was used for a loading dose, and 0.75% ropivacaine was used for maintenance. Recommends elective caesarean delivery under neuraxial anaesthesia wherever possible to reduce the possibility of pulmonary complications secondary to intubation. Cohen et al. [25] Expert opinion Epidural or paravertebral catheter insertion or epidural blood patch (if indicated) should not be postponed for a COVID-19 positive patient. Landau et al. [1] Letter to editor Pathophysiological changes in pregnancy make interpretation of screening results difficult. Tracheal intubation in one patient was reported to have precipitated immediate, prolonged bronchospasm. Treatment of bronchospasm (nebulisation) could possibly cause aerosolisation of viral particles. Lee et al. [19] Case report (for H1N1) H1N1 and superimposed bilateral pneumonia. Epidural analgesia for labour followed by vaginal delivery. No complications reported. Lee et al. [20] Case report Caesarean delivery; hypotension after spinal anaesthesia stabilised after a few boluses of phenylephrine. The placenta, amniotic fluid and cord blood were all negative for SARS-CoV-2 PCR test. Lie, et al. [23] Expert opinion The patient should be assessed, the block performed and the patient allowed to recover, inside the operating room where the surgery will be performed to limit contamination to a single location. Consider digital consent to reduce potential paper contamination. The ultrasound machine's screen and controls protected with a singleuse plastic cover. The CO 2 sampling line can be connected to a 15-mm tracheal tube connector and a high-efficiency particulate air and heat and moisture exchange filters. Healthcare professional involved in performing regional anaesthesia on a COVID-19 patient should, at minimum, don PPE, goggles and a surgical facemask. Attempt to minimise diaphragmatic paralysis by modifying the local anaesthetic dose via volume and concentration or the injection site or technique. Maxwell et al. [24] Expert opinion (for SARS) Neither epidural nor spinal anaesthesia is contra-indicated. Park et al. [21] Case report (for MERS) Emergency caesarean delivery for placental abruption. Use of level 3 PPE (airborne precautions) and negative pressure room. Shanthanna, et al. [26] Expert opinion The duration of immunosuppression may be shorter with dexamethasone and betamethasone compared with other commonly used steroids used as adjuvants. Xia et al. [22] Case report Spinal anaesthesia for emergency caesarean delivery in a patient with moderate to severe COVID-19 disease. No complications reported. Level 3 PPE (airborne precautions) used Zhao et al. [18] Case series (n = 11) Eleven patients received spinal anaesthesia for non-obstetric surgery. No reported anaesthesia-related complications. (continued) under each heading. Although the level of evidence is low for the majority of the above interventions, these recommendations provide a summary of the best available evidence and discuss some uncertainties. The following recommendations apply to a patient with either a suspected or confirmed COVID-19 infection. Reduce the clinical load and perform routine testing as per local guidelines [29] . Neuraxial anaesthesia and peripheral nerve blocks are the first choice (whenever possible) for anaesthetic management of patients with suspected COVID-19 infection [12] . Reducing the volume of surgical procedures allows time for institutions to: plan for a surge of patients with COVID-19; preserve existing stock of PPE; and plan staffing appropriately, particularly as healthcare workers will be quarantined or unwell themselves [30, 31] . This is based on previous governmental regulations implemented during pandemics [32] . All elective operations should be postponed to reduce the risk of exposure of patients and healthcare workers to COVID-19 and to conserve the capacity of the healthcare system, personnel and resources for a possible increase in demand [29] . Therefore, anaesthesia care should be reserved for urgent and emergent surgery. Guidance for triage of non-emergent surgical procedures may vary in different countries and may change during the course of the pandemic [33] . Figure 1 Key recommendations for the performance of regional anaesthesia in suspected or confirmed COVID-19 patients. Recommendations for personal protective equipment for regional anaesthesia in a patient with suspected or confirmed COVID-19 infection. and 28 min, respectively [38] . Alternatively, another report suggests decreasing the inflow while increasing the exhaust can enable the room to remain at neutral pressure while still maintaining laminar flow over the surgical area [37] . The regional anaesthesia procedure for a patient with In a small, retrospective, cohort study, airborne precautions reduced the transmission risk to anaesthetists exposed to mildly symptomatic surgical patients during spinal anaesthesia when compared with contact precautions [14] . Of importance, neither neuraxial anaesthesia nor peripheral nerve blocks are considered to be aerosolgenerating procedures; therefore, applying regular contact and droplet precautions for these low-risk procedures suffice [40] . Personal protective equipment includes a surgical mask, eye protection (goggles or face shield), an impervious surgical gown, and gloves for personnel involved in performing these procedures. The use of respirator masks (e.g. N95 or FFP2/3) is not generally needed but may be considered for prolonged close contact with a COVID-19-infected patient in a closed environment [41] . Keeping this in mind, if the chances of intra-operative conversion to general anaesthesia are significant with the need for airway intervention (an aerosol-generating procedure), it may be appropriate to use a respirator mask. The anticipated urgency and probability of conversion to general anaesthesia is an essential factor when making the decision to wear a respirator mask. Importantly, all patients should wear a surgical mask to restrict the droplet spread [42] . The most experienced person should perform the The presence of an exhaled jet does not necessarily translate into the presence of respirable droplet nuclei or aerosols, as these studies have been conducted using smoke plumes rather than actual detection of infectious aerosols. Also, the concentration of airborne particles is known to decrease over distance, irrespective of other factors such as airflow [46] . It is a common practice to protect the mouth and nose of patients with respiratory infection as this may reduce person-to-person transmission of respiratory infectious viruses. Surgical masks seem to be as effective as respirator masks in decreasing transmission of nosocomial and healthcare worker infections [47] . Based on the above evidence, the use of high oxygen flows through nasal cannulae should be avoided to reduce the risk of possible aerosol generation [48] . If the patient needs supplemental oxygen, an oxygen mask should be preferred over nasal prongs. The flow of supplemental oxygen should be kept to the minimum (preferably < 5 l.min À1 ) needed to maintain arterial oxygen saturation to reduce the risk of aerosolisation [49] . Surgical facemasks can be used over oxygen masks to limit the dispersion of droplets. Minimise the amount of equipment inside the room to what is absolutely essential, and protect the equipment with plastic covers during the procedure. The required equipment and drugs for immediate perioperative care should be prepared and packed in a plastic bag [50] . The ultrasound equipment, including an ultrasound transducer, should be protected from contamination using plastic covers [23] . There is evidence demonstrating that COVID-19 virus particles could remain viable on plastic for up to 3 days [51] . However, as most available disinfectants are effective against SARS-CoV-2, it is recommended that the ultrasound machine be wiped twice, once inside the room and then again outside the room. Adequate time should be given to allow the surface to dry after each wipe [52] . Institutional protocols should be used for decontamination of equipment. negative patients [54, 55] . It is therefore advisable to rule out thrombocytopenia before attempting neuraxial techniques in a COVID-19-positive or suspected patient. A platelet count of 75,000 9 10 6 .l À1 or above has been suggested as an acceptable level for performing of neuraxial procedures in the obstetric population, provided the platelet function is expected to be normal [56] . The use of neuraxial procedures during pregnancy and delivery was reported in early studies from China. A recent review described 14 cases of neuraxial anaesthesia for delivery pooled from four different reports [16] . Fever was reported in all patients, but none had a high white cell A single, small case series suggested the possibility of excessive intra-operative hypotension when prophylactic vasopressors were not used [17] ; however, hypotension following neuraxial anaesthesia has not otherwise been reported. Anaesthetists should be prepared to manage hypotension following neuraxial procedures as for any other patient [57, 58] . Management of post-dural puncture headache As with usual care, pharmacological approaches should be proposed before performing an epidural blood patch. Complications should be discussed on a case-by-case basis. block, extra onset time should be allowed to reduce the risk of conversion. If intra-operative conversion to general anaesthesia is required, the emergency airway procedure should be followed, as described in the literature [49] . Excessive or deep sedation should be avoided to reduce the need for any airway manipulation or interventions. Patients should be recovered in the operating room or an airborne infection isolation room before being transported to a pre-designated area. The patient should be monitored in the operating room until safe and before transfer to a COVID-19 designated area of the hospital, in accordance with local guidelines. It has been shown that the risk of transmission is highest during the doffing of PPE, therefore extra time should be allowed for donning and doffing [61, 62] . Any re-usable equipment utilised during the procedure should be disinfected as per institutional guidelines. The dearth of robust evidence precludes making any strong practice recommendations, despite the COVID-19 pandemic not being the first respiratory pandemic in the last two decades. Current evidence has been generated through individual case series or a retrospective cohort of cases from single institutions. National and societal registries will provide additional data to guide safe practices in the coming months [63, 64] . Individual experiences are vital in formulating treatment plans in the light of an epidemic, and a similar learning lesson was seen during the SARS outbreak when the contributions of the frontline workers and a grounded theory approach helped in formulating a risk management framework and management guidelines for the safe performance of aerosol-generating procedures [65] . A similar effort is needed to generate evidence-based practice recommendations in regional anaesthesia. Future evidence on the disease course may change our recommendations. Lessons learned from first COVID-19 cases in the United States Universal screening for SARS-CoV-2 in women admitted for delivery Imperial College London COVID-19 Response Team High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. Emerging Infectious Diseases 2020 How to risk-stratify elective surgery during the COVID-19 pandemic? Patient Safety in Surgery 2020 Protecting health care workers during the COVID-19 coronavirus outbreak -lessons from Taiwan's SARS response. Clinical Infectious Diseases 2020 Infection prevention and control of epidemic-and pandemic-prone acute respiratory diseases in health care Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Spinal anesthesia is associated with decreased complications after total knee and hip arthroplasty Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study G€ um€ us ß Dem€ ırb€ ılek S. Regional anesthesia in patients with suspected COVID-19 infection Practice recommendations on neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic Spinal anaesthesia for patients with coronavirus disease 2019 and possible transmission rates in anaesthetists: retrospective, single-centre, observational cohort study Obstetric anesthesia during the COVID-19 pandemic Neuraxial procedures in COVID-19 positive parturients: a review of current reports Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients Anesthetic management of patients with COVID 19 Infections during emergency procedures Neuraxial labor analgesia in an obese parturient with influenza A H1N1 Emergency cesarean section on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) confirmed patient Emergency cesarean section in an epidemic of the Middle East respiratory syndrome: a case report Emergency Caesarean delivery in a patient with confirmed coronavirus disease 2019 under spinal anaesthesia Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic Management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (SARS) Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel Is regional anesthesia safe enough in suspected or confirmed COVID-19 patients? ACS Chemical Neuroscience 2020. Epub COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals We asked the experts: Covid-19 outbreak: is there still a place for scheduled surgery? "reflection from pathophysiological data Rapid response of an academic surgical department to the COVID-19 pandemic: implications for patients, surgeons, and the community The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia 2020. Epub Learning from SARS: preparing for the next disease outbreak: workshop summary: National Academies Press COVID-19: guidance for triage of non-emergent surgical procedures Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore Detection of SARS-CoV-2 in different types of clinical specimens Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infectious Diseases 2020. Epub Outbreak of severe acute respiratory syndrome in Singapore and modifications in the anesthesia service Guidelines for environmental infection control in health-care facilities Personal protective equipment during the COVID-19 pandemic -a narrative review Association of Anaesthetists. Personal Protective Equipment (PPE) for clinicians Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) Coronavirus disease (COVID-19) advice for the public: when and how to use masks Airflows around oxygen masks: a potential source of infection? Exhaled air dispersion and removal is influenced by isolation room size and ventilation settings during oxygen delivery via nasal cannula Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer Patients infected with highhazard viruses: scientific basis for infection control Effectiveness of N95 respirators versus surgical masks against influenza: a systematic review and metaanalysis The use of high-flow nasal oxygen in COVID-19 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 Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19 Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 Just the facts: recommendations on point of care ultrasound use and machine infection control during the COVID-19 pandemic Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: a meta-analysis Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Lumbar neuraxial procedures in thrombocytopenic patients across populations: a systematic review and meta-analysis Strategies for prevention of spinalassociated hypotension during Cesarean delivery: are we paying attention? International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia Local anesthetic systemic toxicity: current perspectives Anesthesia Patient Safety Foundation. FAQ on anesthesia machine use, protection, and decontamination during the covid-19 pandemic Risk of self-contamination during doffing of personal protective equipment Contamination during doffing of personal protective equipment by healthcare providers Managing Ebola: lessons learned from the SARS epidemic Additional supporting information may be found online via the journal website.Appendix S1. Search strategy.