What do we know about SARS-Cov-2 and Anesthesia Management?

Review Article

Austin J Anesthesia and Analgesia. 2021; 9(1): 1096.

What do we know about SARS-Cov-2 and Anesthesia Management?

Erdost HA*, Ozbilgin S and Kuvaki B

Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey

*Corresponding author: Hale Aksu Erdost, Department of Anesthesiology and Reanimation, School of Medicine, Dokuz Eylul University, Izmir, Turkey

Received: January 06, 2021; Accepted: February 02, 2021; Published: February 09, 2021


In general, COVID-19 is an acute disease, and the most common symptoms at onset are fever, dry cough, and fatigue, partly with nausea, diarrhea, or other gastrointestinal symptoms [1,2]. Also it has association with neurological symptoms, cardiovascular involvement, and hypercoagulability [3-13]. Anesthesiologists are confronted with these patients not only in intensive care but also in the operating room. In this brief review we focused on what do we know about COVID-19, and how to manage anesthesia and operating room when surgery is needed under the light of our experience and expertise in the field.

Keywords: COVID-19, Perioperative Management, SARS-Cov-2; Novel Coronavirus


In Wuhan, Hubei Province, China first patients with pneumonia of unknown origin were identified in December 2019. On January 7, 2020, the Chinese Center for Disease Control and Prevention and Wuhan City health authorities reported a novel coronavirus from the respiratory tract. The novel coronavirus 2019 officially named severe acute respiratory syndrome coronovirus 2 (SARS-CoV-2) has spread quickly in China and from China to Korea, Japan, Italy, Iran and Singapore. SARS-CoV-2 is an enveloped, single and positive stranded RNA virus. The virus particles have a diameter of about 60-140 nm [1].

In general, COVID-19 is an acute disease, and the most common symptoms at onset are fever, dry cough, and fatigue, partly with nausea, diarrhea, or other gastrointestinal symptoms [1,2]. Patients may develop severe symptoms with diffuse alveolar injury, progressive respiratory failure, and Acute Respiratory Distress Syndrome (ARDS). However, the incidence of less common features like nausea, vomiting, diarrhea and abdominal pain varies significantly among different populations, along with an early and mild onset frequently followed by typical respiratory symptoms [3]. In a review of case series 2-40% of patients had gastrointestinal symptoms (including nausea, vomiting, diarrhoea, abdominal pain) [4,5]. Also Holshue et al. [6] published a case of COVID-19 patient who represented a 2-day history of nausea and vomiting on admission and then developed a slowdown in bowel movement on second day at hospital. Previous studies have shown gastrointestinal system involvement, and this was verified by biopsy of different parts of the gastrointestinal tract. In China minimally invasive autopsies from lung, heart, thyroid, kidney, liver, pancreas, spleen, bone marrow, intestinal tract including stomach and intestine, and skin were performed on three patients died of SARS-CoV-2 pneumonia. While the SARS-CoV-2 is mainly distributed in the lungs, the infection also involves the heart, vessels, liver, kidney, and other organs [7]. Moreover it is known that 36.4% (78/214) of patients with COVID-19 develop neurological symptoms, including headache, disturbed consciousness, and paresthesia. Severely affected patients are more likely to develop neurological symptoms than patients who have mild or moderate disease [8].

Besides these symptoms it has been reported that SARS- CoV- 2 has association with cardiovascular events including myocardial injury [9], myocarditis [10], cardiac arrhythmias [3,11], heart failure [12], and reduced systolic function [13]. In a retrospective cohort study from China SARS-CoV-2 was found to be associated also with hypercoagulable state and risk of venous thromboembolic events like pulmonary embolus [11].

With all these, ocular manifestation can occur such as conjuctival hyperemia and chemosis. Wu et al, [14] reported SARS-CoV-2 could be detected even in tears.

Preoperative management

In addition to emergency surgery in COVID-19 patients, the health care providers should also plan cases, like oncologic surgery or surgeries, which can’t be postponed for a longer period. These cases may be COVID-19 patients or not. How to manage these patients is a considerable issue not only for healthcare staff but also for the patients and their families because there is a high risk of transmission from human to human [15-17]. Studies in China have revealed that tight and methodological infection control rules could provide low infection rates during the perioperative anesthesia period. These rules are essential especially for the health care staff, including anesthesiologists, nurses, and intensive care staff and also cleaning staff working in the operating room. Janbabai et al. [18] explained possible pathways of transmission, which may be from the patient to the healthcare personnel, from healthcare personnel to the patient, between health care personnel and between patients.

The American College of Surgeons has recently proposed a schema to help with triage decision-making for elective cases [19]. Many operations in the region are for cancer or highly symptomatic patients, and as such the current guidance is not to postpone. It is important to recognize that decisions are fluid, and each hospital must make them based on current availability of resources and good clinical judgment.

Preoperative evaluation of the patient: If an undiagnosed but suspicious patient has to undergo urgent surgery, the surgery should not be delayed until the diagnostic tests are concluded. They must follow the same protocols as a patient with proven COVID-19 infection. The rational use of available resources should be prioritized and both stigmatization of patients and unnecessary alarm situations should be avoided.

If there is time, the patient’s file, especially recorded medical history and existing laboratory results, as well as any other available radiologic examinations should be viewed in a safe area before contacting the patient. Reviewing the case with the primary surgeon and the doctor who is treating the patient for COVID may give the anesthesiologist the opportunity to decide about the anesthesiologic approach. The anesthesiologist has to decide if a physical examination and interview with the patient should be done in the ward or if it is suitable to do this in the OR. If the anesthesiologist decides to see the patient on the ward, then Personal Protective Equipment (PPE) should be worn before entering the patient’s room.

At hospitalization of a patient body temperature should be measured. If the body temperature is higher than 37.3°C, the patient should be taken immediately to the clinics for fever disorders and the hospital’s infection authorities should be informed. Chen et al. [20] previously described preoperative anesthetic approach to patients with urgent surgery in the early stages of the pandemic. They suggest, that emergency surgery needs to be handle with a triage model. The primary triage should be done before admission to the hospital. A secondary triage before entering the operating room should be performed by anesthesiologists, including reviewing the medical history, a brief physical examination, and reviewing the chest computed tomography and/or chest x-ray. Also patient’s body temperature should be retaken before entering the OR.

There may be a higher risk of perioperative complications for COVID-19 positive patients and there may be a risk of being infected at the perioperative period for non-COVID-19 patients. Therefore, the informed consent should have added information about COVID pandemia for COVID-19 positive and non-COVID-19 patients. In a retrospective cohort study Lei et al. [21] showed none of the patients had signs or symptoms of COVID-19 before surgery. Remarkably, symptoms of COVID-19 appeared immediately after the completion of surgery, and SARS-CoV-2 infection was confirmed by the laboratory immediately after [21]. Common complications were ARDS (32,4%), secondary infection (29,4%), shock (29,4), arrhthmia (23,5%), acute cardiac injury (14,7 %), and acute kidney injury (5,9%). The same study also showed a 44% increase in intensive care needs and 20% increase in mortality after surgery. These should be definitely kept in mind before making a decision to operate.

Examination: Be aware the patient may not know who you are because of the PPE. For this reason, it is recommended to introduce you before examination. Taking history should be clear and short. Auscultation may not be performed most of the time due to the isolation precautions. After examination and leaving the patient’s room, PPE doffing must be done in a place reserved for this.

In most of the patients common laboratory abnormalities were increase total lymphocytes, prolonged thrombin time, and high lactate dehydrogenase levels. It has been shown in previous studies that patients with abnormal laboratory results require more intensive care. For this reason, complete blood count, biochemistry, coagulation tests and at least chest x-ray tests should be performed in the patient to be operated. As we know about COVID-19 so far, it has multiple clinical presentations which may be associated with cellular immune deficiency, coagulation activation, myocardial injury, hepatic injury, and kidney injury. Therefore tests should include; White blood cell (Neutrophil, Lymphocyte, Monocyte) count, Platelet count, Prothrombin time, Activated partial thromboplastin time, D-dimer, Creatine kinase, Creatine kinase-MB, Lactate dehydrogenase, Alanine aminotransferase, Aspartate aminotransferase, Total bilirubin, Blood urea nitrogen, Creatinine, Hypersensitive troponin I, Procalcitonin [3].

Personal Protective Equipment (PPE)

PPE is essential in all interventions requiring close contact to the patient such as aerosol-generating procedures including endotracheal intubation, manual mask ventilation before intubation, non-invasive ventilation, cardiopulmonary resuscitation, tracheostomy and bronchoscopy, application of high flow nasal cannula “HFNC” or surgical intervention, regional anesthesia, cannulation and catheterization.

Known or suspected COVID-19 patient must be regarded as high risk, so the perioperative management should be considered standard grade 3 PPE, including N95/FPP2, goggles, face shield, gown, protective coverall, protective overshoes All personnel and surgeons must be trained to prevent contamination during wearing and removal of these garments. These precautions are necessary not only to protect themselves, but also to protect each other [22]. Donning and doffing PPE is shown in Table 1 and Figure 1. After the preparation is completed, follow the shortest clean path to the patient.