Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic

Abstract

Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.

Fig. 1

A) The ultrasound machine’s screen and controls are protected with a single-use plastic cover to prevent contamination and to ease disinfection post-procedure. B) Despite being covered in plastic, we were still able to obtain satisfactory images for a popliteal nerve block. CPN = common peroneal nerve; PA = popliteal artery; PV = popliteal vein; TN = tibial nerve.

Fig. 2

The ultrasound probe is covered with a disposable sheath along its entire length so that any part of the probe that potentially may come in contact with the patient is protected. Depending on the type of sheath available, it may need to be extended with the use of more than one sheath. A) For example, the probe sheath in our institution is too short to cover the entire length of the probe, so we cut off one end of a sheath to form a tube and slide it over the probe to cover the proximal half, and then B) use another (sterile) sheath to cover the distal half.

Fig. 3

Set up of capnography monitoring. A) The 15-mm endotracheal tube connector together with a heat and moisture exchanger/filter are connected to the simple face mask. The carbon dioxide (CO₂) sampling line is then connected to the heat and moisture exchanger. B) In an alternative set up, a cut section of a suction catheter is interposed between the simple face mask and the endotracheal tube connector. C) Both setups allowed us to obtain CO₂ tracing and monitor respiratory movements.

Fig. 4

A summary of considerations and practical recommendations aimed at ensuring patient and staff safety, and infection prevention during regional anesthesia for patients with coronavirus disease (COVID-19) infection or infection with other infectious respiratory viral diseases.