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Key Resources For Anesthesiologists Concerning COVID-19

Friday, March 20, 2020
By The TrueLearn Team

Our TrueLearn Anesthesiology Director, Dr. James Lamberg, has compiled a reading list of key research and clinical insight concerning COVID-19.

Dr. Lamberg is an anesthesiologist boarded in critical care medicine, echocardiography, and patient safety. He has been actively involved in preparation for the COVID-19 pandemic at his central Pennsylvania hospital.

TrueLearn extends our gratitude to all the physicians and health care personnel on the front lines of the pandemic. Your dedication and sacrifice inspires us all.

Precautions for Intubating Patients With COVID-19 https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763451

  • If intubation fails, consider placing an LMA instead of mask ventilating
  • Filter with Ambu/BVM reduces particles compared to mask ventilation
  • Double glove for procedure, triple-glove technique is mentioned
  • Eye shield fogging is a potential issue during intubation, alcohol prep on the inside of the googles/shield helps
  • Wet gauze technique around patient’s airway described for reducing sputum particles

Perioperative Management of Patients Infected with the Novel Coronavirus
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763456

  • Full body white gown suggested, along with gloves and eye shields
  • If O.R. is not negative pressure, turn off positive pressure and air conditioning
  • Replace anesthesia machine filters every 3-4 hours during a case
  • General anesthesia is recommended for all patients with suspected or confirmed COVID-19
  • This includes procedures typically under MAC, such as TEE, colonoscopy, etc
  • If not intubated, surgical mask or N95 should be on patient throughout perioperative period
  • Spinal for cesarean section still recommended, mom wears mask as above
  • For recovery, recommended to skip PACU, keep intubated, and go directly to ICU
  • Not recommended to use ventilator during transport, use disposable BVM/Ambu instead
  • Proper order for putting on PPE and taking off PPE described, worth reviewing
  • Video laryngoscope preferred as it creates more distance between patient
  • Note prior presentation incorrectly suggested DL

COVID-19 Infection: Implications For Perioperative and Critical Care Physicians
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763458

  • BPAP/CPAP and high-flow nasal oxygen may be trial, but trial should not exceed 1hr
  • Avoid in decompensating patients, intubate them instead
  • One study showed higher exhaled particle dispersion with low-flow nasal cannula compared to CPAP/BPAP or high-flow nasal
  • Interesting read, may be due to humidified oxygen causing gravity drop of particles
  • “Providers should be aware that coronaviruses can remain infectious on inanimate surfaces for up to 9 days”
  • Any method of preoxygenation is allowable, suggest 5 minutes of 100% oxygen
  • ARDS ventilation (low Vt, plateau < 30, titrated PEEP) and conservative fluids for these patients
  • Includes intraoperative management, limit fluids, keep tidal volumes low
  • Rocuronium may be preferred over succinylcholine, if paralytic wears off pt may cough during prolonged procedure
  • Consider having patients on supplementary oxygen via nasal cannula wear a surgical mask over the tubing
  • Avoid corticosteroids per WHO and CDC, controversial

Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763453

  • About 2.3% of confirmed cases require intubation, > 40% of ICU patients require intubation
  • Mortality rate after ICU admission estimated at 50%
  • Consider liberal intubation criteria (SpO2 < 93% or P/F < 300) to facilitate preparedness for intubation
  • Review of healthcare worker positives in Wuhan show anesthesia providers have excellent survival rate
  • Most healthcare worker infections were early stage of outbreak before PPE mandate

Response of Chinese Anesthesiologists to the COVID-19 Outbreak
https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2763455

  • Approximately 3.5% of healthcare personnel were infected
  • Dramatic measures taken initially, however, it quickly became apparent that the number of beds was far from adequate
  • Hence Wuhan rapidly built additional hospitals
  • Chinese Society of Anesthesiology and Chinese Association of Anesthesiologists jointly established a platform providing free mental health advice to all anesthesia providers
  • Simulations and drills aimed at preparedness for infectious mass emergency should be organized

Principles of Airway Management in Coronavirus COVID-19 – An Infographic by the Department of Anaesthesia and Intensive Care, Prince of Wales, Hong Kong
https://www.wfsahq.org/components/com_virtual_library/media/d6b96b32880ef98a533a191bf1247b3b-covid-19-airway-management-infographic.pdf

A Seattle Intensivist’s One-pager on COVID-19 – Nick Mark, MD
https://www.onepagericu.com/

Recommendations for Airway Management in a Patient with Suspected Coronavirus (2019-nCoV) Infection – APSF
https://www.apsf.org/wp-content/uploads/news-updates/2020/apsf-coronavirus-airway-management-infographic.pdf

Surge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement
https://journal.chestnet.org/article/S0012-3692(15)51987-9/pdf

Sequence for Donning and Removing Personal Protective Equipment – CDC
https://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf

Anesthesia Patient Safety Foundation
https://www.apsf.org/novel-coronavirus-covid-19-resource-center/

American Society of Anesthesiologists
https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information

Disaster Planning Videos

Augmenting Critical Care Capacity During a Disaster
http://sccmmedia.sccm.org/documents/LMS/Augmenting-Critical-Care-Capacity-During-Disaster/story_html5.html

Sustained Mechanical Ventilation Outside Traditional ICU
http://sccmmedia.sccm.org/documents/LMS/Sustained-Mechanical-Ventilation-Outside-ICU/story_html5.html

ICU Microcosm Within Disaster Medical Response
http://sccmmedia.sccm.org/documents/LMS/ICU-Microcosm-within-Disaster-Medical-Response/story_html5.html

Disaster Triage and Allocation of Scarce Resources
http://sccmmedia.sccm.org/documents/LMS/Disaster-Triage-Allocation-Scarce-Resources/story_html5.html

COVID-19 Preparedness Checklist for Intensive Care Units
http://www.sccm.org/Disaster/COVID-19-ICU-Preparedness-Checklist

N95 Filtering Facemask Respirator Ultraviolet Germicidal Irradiation (UVGI) Process for Decontamination and Reuse
https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf