Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective

Abstract

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada.

Keywords: education; epidemiology; obstetrics; postoperative complications; regional anesthesia.

Figure 1

In situ simulation training layout showing the organization of simulated training in operation room with regional anesthesia set up and infection control practices training. OR, operating room; PAPR, powered air purifying respirators; RA, regional anesthesia.

Figure 2

Showing the systematic approach for considering regional anesthesia in COVID-19 patients. *Hypertension is a common presentation in COVID-19 due to the interactions of the virus with the angiotensin converting enzyme (ACE2): a false normal blood pressure could be early signs of deterioration in a previously hypertensive COVID-19 presentation a.# Sepsis with white cell count > 15x10^∧9/L are relative contraindications for CNB, COVID-19 patients might present with lymphopenia and cardinal manifestations of sepsis may not be seen. CNB, central neuraxial block; CO, cardiac output; ECMO, extra corporeal membrane oxygenation; GA, general anesthesia; POCUS, point of care ultrasound that includes transthoracic echocardiography (TTE), lung ultrasound and IVC scan for volume status; PNB, peripheral nerve block; SpO2-percentage oxygen saturation of hemoglobin; SVR, systemic vascular resistance when measured by non-invasive pulse contour analysis through peripheral arterial pressure.