Episode #10 Covid-19 and Anesthesia Clinical Care FAQ

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

Today, we are going to return to the APSF Novel Coronavirus Resource Page. You can find this page from the APSF homepage and clicking on the Patient Safety Resource link at the top of the page and it is the first one down to enter the APSF Novel Coronavirus Resource Center.  I know that we have been here before, but we are going to explore a new area today. I am sure that some of you have questions about patient safety during this pandemic, so today we are going to look at the Covid-19 and Anesthesia FAQ section. I hope that you will follow along  by scrolling down to the frequently asked questions section and clicking on the first one.

Before we dive into today’s episode, we’d like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Preferred Physicians Medical Risk Retention Group – we wouldn’t be able to do all that we do without you!”

And now we are back to review the Covid-19 and Anesthesia FAQ.  These frequently asked questions have been put together in collaboration between the APSF and the ASA. Here’s our disclaimer.  Keep in mind that you should use this information with appropriate medical and legal counsel and make your own determinations as to the relevance to your practice setting and compliance with state and federal laws and regulations. We have done our best to provide accurate information, but this is intended for information only and does not constitute medical or legal advice.  If you would like to submit a clinically related question please do so at [email protected] and I will include the link in our show notes.

We are going to review several of the FAQs about clinical care, so under the table of contents, click on Clinical Care and you will be taken to the section.  Many institutions are up and running and while operations are resuming, this is definitely a new normal.  Our first question under clinical care is: “Why are anesthesiologists and other anesthesia professionals being asked to perform more intubations in my facility when there are other physicians who are trained to do so?” Here is the answer. Intubations may be performed in the operating room, ICU, or emergency department and in each of these locations, it is important that the most experienced professional depending on availability and staffing for the facility perform the intubation.  It is important that every facility develop a protocol that outlines the physicians that respond to non-OR intubations keeping in mind that this is not a good training opportunity for students.  Anesthesiologists may be consulted for difficult intubations or to assist with overwhelming numbers of intubations during a hospital surge.  I will include a link to the ASA recommendations for healthcare providers when caring for patients with known or suspected Covid-19 in the show notes.  Anesthesiologists may be called upon to work with hospital administrators and critical care and emergency departments to provide clear guidance for performing intubations that protects healthcare workers and helps to ensure patient safety. After intubation events is a good time for debriefing with the team to figure out how to improve the process in the future.

Question #2 asks what should we do about “MAC” cases, with an open airway?  This is a great question.  It is important to consider contamination of the anesthesia workspace and the operating room as well as the safety of the anesthesia professional and colleagues in the operating room during the case.  If dispersion of potentially contaminated exhaled gases from an open airway is a risk, this is a good time to consider alternate anesthesia plans.

For our next question, we are moving into the endoscopy suite. “Are there specific recommendations for EGD procedures and other procedures with a high risk of aerosolization?”  The answer to this depends on the local community spread in your area in consultation with local infectious disease and infection control experts.  It is important to consider the patient, the skills of the endoscopists, and local resources.  We know that endotracheal tubes provide the most secure airway, but this is not the only options.  Another option includes patient face masks with openings for gastroscopes such as the Procedural Oxygen Mask by Curaplex or other similar devices to help decrease dispersion throughout the room.  During the procedure, it is also important to wear appropriate PPE. There is no uniform best practice for these procedures since it depends on availability of N95 masks, personal protective equipment, patient testing, and regional differences in known patients with Covid-19.

We are going to move over to the Obstetric floor for our next questions. “With regard to COVID-19, do APSF and ASA have any recommendations for obstetric care overall and specifically related to epidurals and spinals?”  In answer to this question, there is a recent statement published by the Society for Obstetric Anesthesia and Perinatology and I encourage you to check it out and I will include a link in the show notes.  For OB anesthesia care, there does not appear to be a coronavirus-related contraindication for a neuraxial block.  During these procedures, it is important to take precautions especially for patients with known or suspected Covid-19 including isolating patients with known or suspected Covid-19 in a designated room and having a dedicated operating room available as well.  While performing a neuraxial procedure, it is also recommended to wear an N95 mask, double gloves, gowns, and protective eyewear in patients with known or suspected Covid-19.

Our next question brings us back into the operating room.  “Given the concern for immunosuppressive during this time of COVID-19, I question whether or not to administer dexamethasone for PONV. According to one article, it doesn’t look like in the doses we provide for PONV prophylaxis- that it would cause clinically significant suppression but was wondering if you might be able to comment.” This is such a good question because it is asking about a drug we often give for PONV prophylaxis, but just trying to make sure that we keep our patients safe during this pandemic. It appears that low dose or a single dose of dexamethasone is not clinically significant and does not lead to sustained immunosuppression. Keep in mind, though, that every patient is unique so you will want to carefully consider your individual patient and the treatment options. There is no clinical data at this time about whether to use or not sure a single dose of dexamethasone in Covid-19 patients. The nature of this pandemic is that there is still so much to learn.

The next question also asks about concerns of immunosuppression when performing steroid injections in the elderly population as it relates to Covid-19.  Once again, there is no specific guidance on epidural steroid injections and Covid-19 patients, but it is important to assess each patient carefully and perhaps consider decreasing the dose of steroid administered especially since the effect of long acting steroids will last for a while after administration.

The next question look at yet another important area for patient care, Regional anesthesia. So, “What is the APSF and ASA’s stance on safety of regional anesthesia in appropriate patients (especially those who haven’t been tested) vs general anesthesia?”

Just like in our obstetric patients, we are not aware of a contraindication to a neuraxial block due to the coronavirus infection, so you may proceed with spinals and epidurals for these patients with appropriate precautions and PPE.  For regional blocks, the American Society of Regional Anesthesia and Pain Medicine or ASRA has published Practice Recommendations on Neuraxial Anesthesia and Peripheral Nerve Blocks during the COVID-19 Pandemic which is a Joint Statement by the American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA). You can find this on the ASRA website which I will link to in the show notes. The use of regional anesthesia does not appear to be contraindicated in patients with known or suspected Covid-19 and there is no dose adjustment recommended at this time. These procedures are not considered aerosol-generating, but the use of an N95 mask may be considered for procedures that involve close contact of longer durations or if you are in the operating room and there is a higher probability of conversion to general anesthesia. In addition, remember patients should be wearing a surgical mask as well to decrease droplet spread.

Let’s move on to question #8 which asks about the use of a video laryngoscope as first line for intubation and what to do at institutions where there is limited supply.  The recommendation at this time highlights that providers perform intubations with the greatest chances of success on the first attempt and at the same time you will also need to consider the supply chain.  To safely perform these intubations and help keep our patients safe, there will need to be coordination with your healthcare system to monitor the supply chain and determine the best use for any limited resources. And remember, in the locations where intubations take place, the most experiences professional for that location should perform the intubation.  This will help to protect the healthcare providers in the room as well as the patient.

Question #9 asks about what to do with the plastic draping on any video laryngoscope that comes in to the room for an intubation for a patient with known or suspected Covid-19. If you have ample supplies, then this plastic draping should be discarded carefully after use. In the event of limited supplies, you may consider wiping down the draping using appropriate cleaning procedures designated by the manufacturer.

We have discussed intubation procedures, but what about when we need to provide supplemental oxygen to a patient who is wearing a mask and who has or may have Covid-19? The first step is to remember your safety and the safety of the healthcare providers in the room.  Appropriate PPE is vital even when an intubation is not being performed.  When you are close to a patient with Covid-19, there is a risk for the patient coughing in close proximity to you.   Plus, you may need to provide airway support with jaw thrust or intermittent positive pressure ventilation with a face mask. This is still the time to wear PPE for aerosol-generating procedures since there will not be time to don safely if the clinical course changes quickly. For a stable patient, you may consider using nasal cannula with low flows under a surgical mask or a face tent over the patient’s surgical mask. Higher oxygen flows may increase the risk of aerosolization of Covid-containing respiratory secretions.  In order to keep patients and healthcare providers safe, you will need to evaluate each patient and case to balance oxygen flow levels, adequate patient oxygenation, and the need for additional airway support with an endotracheal tube or LMA.

Speaking of LMA use, let’s take a look at question #11. “What is the recommendation for LMA usage or MAC anesthesia? Or are we presuming ALL patients are carriers and LMA usage and MAC anesthesia should be minimized? This would result in intubating all patients for general anesthesia and eliminating MAC anesthesia for most of our cases.”

This is a great question and the answer reflects the additional knowledge that we have gained since the beginning of the pandemic.  The use of an LMA depends on the patient and surgical case as well as a risk assessment based on local community-wide transmission. You can also help evaluate the results of a patient’s preoperative Covid-19 test, keeping in mind the sensitivity, specificity, and timing of the tests being used. It may be helpful to discuss the policy on LMA use with local infection prevention experts at your institution.  We still do not have a study that assesses the risk of various airway techniques and anesthetic choices. An LMA can usually provide a closed airway at low pressures, but there may be a leak around the LMA at higher pressures leading to aerosol production and increased risk for contamination in the OR. On the other hand, you may want to consider using an LMA depending on the patient and the case given the lower risk of coughing.  For MAC cases, it is important to think about how close anesthesia professionals are to the patient’s head especially if we need to provide jaw lifts or intermittent positive pressure ventilation during moments of brief apnea.  Wearing PPE for aerosol-generating procedures is a good idea to help stay safe during these cases.  Remember that airway cases, upper endoscopy, bronchoscopy and other cases that may induce patients to cough and sneeze are high risk for aerosol production. We may not be the only providers near the patient’s head…in fact, the gastroenterologist society recommendations provide information about wearing PPE for procedures as well as appropriate screening and follow-up for patients. I will include a link to their recommendations in the show notes.   Another consideration for MAC cases is that a failed MAC case may require urgent conversion to general anesthesia and airway manipulation, and communication with the entire team in the operating room and wearing appropriate PPE during this time period is important to minimize the risk of contamination.  There are so many more excellent questions to review so be sure to check out the APSF website and the show notes.

That’s all the time we have for today!! Thank you so much for joining us today on this journey towards improved patient safety. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Plus, you can find us on twitter @APSForg.  Follow along with us for additional patient safety information tweets!!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2020, The Anesthesia Patient Safety Foundation