Neuraxial anaesthesia and peripheral nerve blocks during the COVID-19 pandemic: a literature review and practice recommendations

Association between anesthesia technique and death after hip fracture repair for patients with COVID-19

PURPOSE

Patients with COVID-19 undergoing hip fracture surgeries have a 30-day mortality of up to 34%. We aimed to evaluate the association between anesthesia technique and 30-day mortality after hip fracture surgery in patients with COVID-19.

METHODS

After ethics approval, we performed a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program data set from January to December 2021. Inclusion criteria were age ≥ 19 yr, laboratory-confirmed SARS-CoV-2 infection within 14 days preoperatively, and hip fracture surgery under general anesthesia (GA) or spinal anesthesia (SA). Exclusion criteria were American Society of Anesthesiologists Physical Status V, ventilator dependence, international normalized ratio ≥ 1.5, partial thromboplastin time > 35 sec, and platelet count < 80 × 109 L-1. The primary outcome was all-cause 30-day mortality. The adjusted association between anesthetic technique and 30-day mortality was analyzed using multivariable logistic regression.

RESULTS

Of 23,045 patients undergoing hip fracture surgery, 331 patients met the study criteria. The median [interquartile range] age was 82 [74-88] yr, and 32.3% were male. The 30-day mortality rate was 10.0% (33/331) for the cohort (10.7%, 29/272 for GA vs 6.8%, 4/59 for SA; P = 0.51; standardized mean difference, 0.138). The use of SA, compared with GA, was not associated with decreased mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.21 to 1.8; E-value, 2.49).

CONCLUSION

Anesthesia technique was not associated with mortality in patients with COVID-19 undergoing hip fracture surgery. The findings were limited by a small sample size.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT05133648); registered 24 November 2021.

More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health

Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.

Patients' caring experience during procedures under regional anesthesia in Mainland China: A phenomenology study

Background

Although regional anesthesia is common, the procedure results in feelings of uncertainty and anxiety in some patients. Increased care is needed for these patients under general anesthesia. Few studies have focused on the intraoperative caring experience of patients during regional anesthesia. This study focused on the caring experience of patients during procedures involving regional anesthesia.

Methods

The descriptive phenomenology method of Husserl was employed. Semi-structured interviews were conducted with a purposive sample in five Grade III-A hospitals in Zhengzhou City, Henan Province. The seven-step analysis method of Colaizzi was applied for the analysis, summation, and theme refinement of the interview data.

Results

A total of 14 patients from five hospitals participated in the interviews. Four domains and 16 themes emerged during analysis: be informed (about the operation site, progression of the operation, informed in advance, receive explanation for abnormal experience); take care of my body (painless, gentle movements, special care); be protected (work seriously, favorable atmosphere, skilled, authority); and treated as an individual (pay attention, accompany, ask for opinions, encourage patient expression, humorous).

Conclusion

Patients during procedure under regional anesthesia had specific caring experiences relative to other patients. Medical staff should recognize the importance of regional anesthesia patients' intraoperative caring experience. Hospital administrators should offer support to allow healthcare staff to provide targeted caring for patients during procedure under regional anesthesia.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.

Impact of SARS-CoV-2 infection on postoperative complications of patients undergoing surgery after general outbreak in China: a protocol for multicentre prospective cohort study

INTRODUCTION

There is currently limited evidence addressing perioperative prognosis of surgical patients during COVID-19 pandemic; especially targeting on the Chinese population since the wave in 2022. Considering a distinct feature from the rest of the world demonstrated and the fast mutation and spread of the virus, evidence most relevant to China is urgently in need. The objective of this study is to seek for supporting evidence via evidence-based risk evaluations for postoperative complications to accumulate experience for coming infection waves.

METHODS AND ANALYSIS

This protocol proposes a multicentral, prospective, observational cohort study aiming to explore the link between SARS-CoV-2 infection and postoperative complications among surgical patients under general or regional anaesthesia between 16 January 2023 and 31 December 2023. A retrospective cohort covering the same period in 2019 is extracted for historic reference. Data are extracted from the health information system and anaesthesia information management system. The COVID-19 information is collected via an online survey. Missing values in weight or height will be imputed by each other with age and gender via multiple imputation. Other missing values will not be handled specially. Standard descriptive statistics will be reported followed by statistical modelling. Binomial regression with logit link is used for binary outcome. The time-to-event outcome is analysed using Cox regression with discharge from hospital further treated as a competing state. Hierarchical models will be assessed to account for temporal or central random effects. Temporal trends will be displayed with future expectations.

ETHICS AND DISSEMINATION

Ethical approval is obtained from the ethical committee in Xijing Hospital (No. KY20232002-C-1); approvals are expected for each participating institute. Verbal consent will be informed and obtained prior to online survey collection. Personal information remains confidential, and publications will be deidentified.

TRIAL REGISTRATION NUMBER

NCT05677815.

Exploration and Application of the Peri-anesthesia Nursing Management Mode of the Five-Sphere Integrated Plan

Objectives: The objective of this research was to test the application of peri-anesthesia nursing management (anesthesia preparation room, operating room, recovery room, post anesthesia visit, and anesthesia general management) on hospital services. Methods: We used a quantitative research design to collect data from 311 nurses, with structural equation modeling used for data analysis. Results: The application of the peri- anesthesia nursing management mode of the five-sphere integrated plan impacted hospital services for patients. Conclusion: The practice of the five-sphere integrated mode not only highlighted the professional characteristics of anesthesia nursing, but also ensured the quality of medical treatment of patients during peri-anesthesia, and provided new ideas and references for nursing management of other specialties.

Retailoring training programmes in anaesthesia and intensive care after the coronavirus disease 2019 outbreak

PURPOSE OF REVIEW

In this review, we want to collect all the adaptations that anaesthesiology training has faced because of the health crisis and social distancing measures resulting from coronavirus 2019 disease (COVID-19). We reviewed new teaching tools launched during the COVID-19 outbreak worldwide and particularly those implemented by the European Society of Anaesthesiology and Intensive Care (ESAIC) and the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC).

RECENT FINDINGS

Globally, COVID-19 has interrupted health services and all aspects of training programmes. These unprecedented changes have led to teaching and trainee support innovation tools, focusing on online learning and simulation programmes. Airway management, critical care and regional anaesthesia, have been enhanced during the pandemic, while there were major obstacles in paediatrics, obstetrics and pain medicine.

SUMMARY

The COVID-19 pandemic has altered profoundly the functioning of health systems worldwide. Anaesthesiologists and trainees have fought on the front lines of the battle against COVID-19. As a result, training in anaesthesiology during the last 2 years has focused on managing patients in intensive care. New training programmes have been designed to continue teaching residents of this speciality, focusing on e-learning and advanced simulation. It is necessary to present a review describing the impact that this turbulent period has had on the different subsections of anaesthesiology and to review the innovative measures that have been implemented to address these possible deficits in education and training.

Combinations of nerve blocks in surgery for post COVID-19 pulmonary sequelae patient: A case report and review of literature

BACKGROUND

Regional anesthesia is a promising method in patients with post coronavirus disease 2019 (COVID-19) pulmonary sequelae for preserving pulmonary function and preventing postoperative pulmonary complications, compared with general anesthesia.

CASE SUMMARY

We provided surgical anesthesia and analgesia suitable for breast surgery by performing pectoral nerve block type II (PECS-II), parasternal, and intercostobrachial nerve blocks with intravenous dexmedetomidine administration in a 61-year-old female patient with severe pulmonary sequelae after COVID-19 infection.

CONCLUSION

Sufficient analgesia for 7 h was provided via PECS-II, parasternal, and intercostobrachial blocks perioperatively.

COVID and Perioperative Considerations

Coronavirus (COVID) pandemic has affected the majority of people worldwide. Patients with COVID infection might require emergent or elective surgeries. COVID-related perioperative considerations to reduce infection spread include changing the workflow to include protective gear for patients and health-care personnel, COVID-dedicated operating rooms, and appropriate perioperative management of the patient with or presumed COVID infection. COVID-specific changes to operating room environment are done. Disinfection guidelines are followed. Anesthesia considerations pertaining to pre-operative optimization of patient’s condition and prevention of spread of infection to others are foremost.

Segmental Thoracic Spinal Anesthesia for Laparoscopic Cholecystectomy with the "Hypobaric" Technique: A Case Series

Purpose

Several studies have applied lumbar spinal anesthesia (SA) with isobaric/hyperbaric bupivacaine and opioids in elective laparoscopic cholecystectomy (LC), documenting a superiority of the methodic over general anesthesia (GA) in terms of perioperative pain, nausea, and vomiting, though with a notable incidence of intraoperative right shoulder pain, potentially responsible for conversion to GA. This case series presents an opioid-free scheme of segmental thoracic spinal anesthesia (STSA) with hypobaric ropivacaine, reporting its benefits mainly in terms of shoulder pain occurrence.

Patients and Methods

Hypobaric STSA was performed in nine patients undergoing elective LC between May 1 and September 1, 2022. The level of the needle insertion was included between T8 and T9, via a median or a paramedian approach. Midazolam (0.03 mg/kg) and Ketamine (0.3 mg/kg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 5 mg and then isobaric ropivacaine at a dose of 10 mg. Patients were placed in anti-Trendelenburg position for the entire duration of surgery. LC was conducted through the standard 3 or 4 ports technique with pneumoperitoneum maintained at a pressure of 8-10 mmHg.

Results

Mean patient age was 75.7 (±17.5) years, with a mean ASA score and Charlson comorbidity index (CCI) of 2.7 (±0.7) and 4.9 (±2.7), respectively. STSA was completed without complications in all patients, with no need for conversion to GA. Mean operative time and SA duration were 37.5 (±8.7) and 145.2 (±21.8) min, respectively. Intraoperatively, no shoulder or abdominal pain and nausea were reported, with only four and two patients requiring vasopressor and sedative intravenous drugs, respectively. Postoperatively, overall mean VAS pain score and within the first 12 hafter surgery were 3 (±2) and 4 (±2), respectively. Median length of stay was 2 (range = 1-3) days.

Conclusion

Hypobaric opioid-free STSA appears to be a promising approach for laparoscopic surgeries, with minimal to null occurrence of shoulder pain. Larger prospective studies are required to validate these findings.

Impact of Pandemic Response on Training Experience of Anesthesiology Residents in an Academic Medical Center: A Retrospective Cohort Study

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic substantially altered operations at hospitals that support graduate medical education. We examined the impact of the pandemic on an anesthesiology training program with respect to overall case volume, subspecialty exposure, procedural skill experience, and approaches to airway management. Methods Data for this single center, retrospective cohort study came from an Institutional Review Board approved repository for clinical data. Date ranges were divided into the following phases in 2020: Pre-Pandemic (PP), Early Pandemic (EP), Recovery 1 (R1), and Recovery 2 (R2). All periods were compared to the same period from 2019 for case volume, anesthesia provider type, trainee exposure to Accreditation Council for Graduate Medical Education (ACGME) index case categories, airway technique, and patient variables. Results 15,087 cases were identified, with 5,598 (37.6%) in the PP phase, 1,570 (10.5%) in the EP phase, 1,451 (9.7%) in the R1 phase, and 6,269 (42.1%) in the R2 phase. There was a significant reduction in case volume during the EP phase compared to the corresponding period in 2019 (-55.3%; P < .001) that improved but did not return to baseline by the R2 phase (-17.6%; P < .001). ACGME required minimum cases were reduced during the EP phase compared to 2019 data for pediatric cases (age < 12 y, -72.1%; P < .001 and age < 3 y, -53.5%; P < .006) and cardiopulmonary bypass cases (52.3%, P < .003). Surgical subspecialty case volumes were significantly reduced in the EP phase except for transplant surgery. By the R2 phase, all subspecialty volumes had recovered except for plastic surgery (14.9 vs. 10.5 cases/week; P < .006) and surgical endoscopy (59.2 vs. 40 cases/week; P < .001). Use of video laryngoscopy (VL) and rapid sequence induction and intubation (RSII) also increased from the PP to the EP phase (24.6 vs. 79.6%; P < .001 and 10.3 vs. 52.3%; P < .001, respectively) and remained elevated into the R2 phase (35.2%; P < 0.001 and 23.1%; P < .001, respectively). Conclusions The COVID-19 pandemic produced significant changes in surgical case exposure for a relatively short period. The impact was short-lived, with sufficient remaining time to meet the annual ACGME program minimum case requirements and procedural experiences. The longer-term impact may be a shift towards the increased use of VL and RSII, which became more prevalent during the early phase of the pandemic.

Did the COVID-19 Pandemic Change the Anaesthesia Preferences of Pregnant Women for Caesarean Section?

OBJECTIVE

The COVID-19 disease has become a new cause of anxiety for pregnant women regarding caesarean sections. The purpose of the present study was to investigate the anaesthesia preferences of pregnant women who preferred general anaesthesia in their previous caesarean sections during the COVID-19 pandemic.

METHODS

A total of 140 pregnant women between the ages of 18 and 45, who had undergone elective caesarean section under general anaesthesia, were included in the study. Amsterdam Preoperative Anxiety and Information Scale and Beck Anxiety Inventory were applied. The primary cause of anxiety and anaesthesia preference was asked and recorded.

RESULTS

It was found that 50.7% (71/140) of the pregnant women who preferred general anaesthesia in their previous caesarean sections preferred regional anaesthesia during the COVID-19 pandemic. It was also found that patients with primary anxiety because of COVID-19 contagion preferred regional anaesthesia more (36/55), and the primary reason for anxiety in these patients was COVID-19 contamination anxiety (36/71).

CONCLUSIONS

Informing the patients about the pandemic precautions in the surgery room and in the hospital during the pandemic, as well as routine information in the preoperative anaesthesia appointment, may be effective in the choice of regional anaesthesia, which is considered to have a low risk of transmission.

Regional Anaesthesia in the Post-COVID Era

COVID-19 pandemic has changed clinical practice significantly. Trying to avoid airway manipulation to reduce viral transmission favoured regional anaesthesia techniques over general anaesthesia when feasible. In this case report, we share the anaesthetic care of a 45-year-old male with a history of intensive care unit admission due to COVID, positive pressure ventilation, and ECMO support. The patient was diagnosed with cubital tunnel syndrome, and his treatment was successfully applied as surgical release under infraclavicular block. This case is discussed in relation to recent trends in anaesthesiology, regarding patients with COVID-19 history.

Pattern of Perioperative Surgical Patient Care, Equipment Handling and Operating Room Management During COVID-19 Pandemic at Jimma Medical Center

BACKGROUND

The nature of COVID-19 transmission creates significant risks in surgical departments owing to the close contact of medical staff with patients, the limited physical environment of the operating room and recovery room, the possibility of shared surgical equipment and challenges in the delivery of surgical care in all surgical departments. Globally, studies have reported that the effects of the pandemic on surgical departments are profound, potentially long-lasting and extensive. To manage these effects, different local guidelines and recommendations have been developed, with potential differences in their effectiveness and implementation. Therefore, harmonized and effective national/international guidelines for specific surgical departments during perioperative periods are pertinent to curtail the infection, and will inevitably need to be adapted for consistent and sustainable implementation by all medical staff. The pattern of surgical patient care during the COVID-19 pandemic at Jimma Medical Center (JMC), Ethiopia, has not been explored yet. The present study aimed to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC.

METHODS

A cross-sectional study was conducted to describe the pattern of perioperative surgical patient care, equipment handling and operating room management during the COVID-19 pandemic at JMC, using five-point Likert scales (0, not at all; 1, rarely; 2, sometimes; 3, most of the time; 4, frequently). A total of 90 respondents [35 patients (five patients from each of seven surgical departments) and 55 healthcare providers (six professionals from each of nine units, including the center of sterility room and anesthesia)] who were available during the study period, selected by a convenience sampling technique with multistage clustering, participated in the study. Data were collected using a structured questionnaire via direct observation and face-to-face interviews with patients undergoing surgery, healthcare providers and hospital administrators, against the standard surgical patient care guidelines. The collected data were manually checked for missing values and outliers, cleared, entered into EpiData (v4.3.1) and exported to SPSS (v22) for analysis. The mean score of practice was compared among different disciplines by applying the unpaired t-test. The findings of the study were reported using tables and narration. A p-value of less than 0.05 was declared as statistically significant.

RESULTS

Despite the surgical care practice having changed during the COVID-19 pandemic in all service domains, it is not implemented consistently among different surgical departments owing to different barriers (lack of training on the updated guidelines and financial constraints). The majority of surgical staff were implementing the use of preventive measures against COVID-19, while they were practiced less among patients. The guidelines for surgical practice during the preoperative phase were well applied, especially screening patients by different methods and the application of telemedicine to reduce physical contacts. But, against guidelines, elective patients were planned and underwent surgery, especially in the general surgery department. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. The extent of practice for anesthesia care, operating room management and postoperative care in the recovery room also changed, and the guidelines were sometimes applied.

CONCLUSION AND RECOMMENDATIONS

Although perioperative surgical care practice differed before and during the pandemic, the standard guidelines were inconsistently implemented among surgical departments. The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. Thus, the authors developed safe surgical care guidelines throughout the different domains (infection prevention and PPE use; preoperative care, intraoperative care, operating room management, anesthesia care, equipment handling process and postoperative care) for all disciplines and shared them with all staff. We recommend that all surgical staff should access these guidelines and strictly adhere to them for surgical service during the pandemic.

Surgical treatment for fragility hip fractures during the COVID-19 pandemic resulted in lower short-term postoperative functional outcome and a higher complication rate compared to the pre-pandemic period

The COVID-19 pandemic adversely affected the functional outcomes of fragility hip fracture patients. This study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among patients treated during the pandemic. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.

INTRODUCTION

This study aims to investigate the in-hospital complication rate and short-term postoperative functional outcomes of fragility hip fracture (FHF) patients compared between during the COVID-19 pandemic and the same 14-month time period 1 year prior to the pandemic.

METHODS

Using data from the Siriraj Fracture Liaison Service registry, FHF patients treated during the COVID-19 pandemic (1 March 2020 to 30 April 2021) were time-matched with FHF patients treated during the pre-pandemic period (1 March 2018 to 30 April 2019). We collected the rate of in-hospital postoperative complications and the postoperative functional outcomes at discharge and 3 months as measured by the Barthel Index (BI) and EuroQol visual analog scale (EQ-VAS). Functional outcome measures were compared between the pre-pandemic and pandemic periods.

RESULTS

There were 197 and 287 patients in the pre-pandemic and pandemic groups, respectively. At the 3-month postoperative follow-up, the mean postoperative BI score and change in BI score were both significantly lower in the pandemic group indicating poorer postoperative function. Moreover, FHF patients treated during the pandemic had significantly more in-hospital complications (36.6% vs. 22.8%, p = 0.002). There was no significant difference in the 3-month EQ-VAS or change in the EQ-VAS between groups.

CONCLUSION

The results of this study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among FHF patients treated during the COVID-19 pandemic compared to the pre-pandemic period. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.

Regional anesthesia global health collaborations- a scoping review of current intervention methods

PURPOSE OF REVIEW

Perioperative anesthesia-related mortality is significantly higher in low-resource compared to high-resource countries. Regional anesthesia techniques can provide safety, cost, and access benefits when compared to general anesthesia in these settings but is underutilized primarily due to a lack of experienced educators and training opportunities. Academic institutions and international organizations are attempting to fill this educational gap through collaborations, but these efforts need examination for best practices going forward.

RECENT FINDINGS

Most collaborative anesthesia interactions between high and low resource areas have occurred between North America or Europe, and Africa or Asia and a majority have involved an educational intervention. Only 7% of the studies used a recognized framework to evaluate the intervention used in their research, such as the Kirkpatrick, REAIM or CFIR method. All recent studies reviewed reported a positive impact from educational collaborations. Only 7% of interventions have had a primary focus on regional anesthesia and most were reported between 2016 and 2022.

SUMMARY

Robust reports on international collaborations providing capacity enhancing educational interventions in regional anesthesia have increased in recent years but are still rare and should be encouraged going forward. Short courses supported by high-resource countries can be effective in low-resource areas when partnerships produce curricula that are well designed.

Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review

OBJECTIVE

To map the recommendations for hospitalised patient safety in the context of the COVID-19 pandemic.

DESIGN

Scoping review using the method recommended by the Joanna Briggs Institute.

DATA SOURCES

Databases: Medline, SCOPUS, EMBASE, ScienceDirect, LILACS, CINAHL and IBECS; grey literature platform: Google Scholar; and 11 official websites of leading healthcare institutions were searched on 27 April 2021 and updated on 11 April 2022.

ELIGIBILITY CRITERIA

We included documents that present recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic, published in any language, from 2020 onwards.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed in pairs with consensus rounds. A descriptive analysis was carried out to present the main characteristics of the articles. Qualitative data from the extraction of recommendations were analysed through content analysis.

RESULTS

One hundred and twenty-five documents were included. Most papers were identified as expert consensus (n=56, 44.8%). Forty-six recommendations were identified for the safety of hospitalised patients: 17 relating to the reorganisation of health services related to the flow of patients, the management of human and material resources and the reorganisation of the hospital environment; 11 on the approach to the airways and the prevention of the spread of aerosols; 11 related to sanitary and hygiene issues; 4 about proper use of personal protective equipment and 3 for effective communication.

CONCLUSIONS

The recommendations mapped in this scoping review present the best practices produced so far and serve as a basis for planning and implementing good practices to ensure safe hospital care, during and after COVID-19. The engagement of everyone involved in the care of hospitalised patients is essential to consolidate the mapped recommendations and provide dignified, safe and quality care.

Patterns of Skills Acquisition in Anesthesiologists During Simulated Interscalene Block Training on a Soft Embalmed Thiel Cadaver: Cohort Study

BACKGROUND

The demand for regional anesthesia for major surgery has increased considerably, but only a small number of anesthesiologists can provide such care. Simulations may improve clinical performance. However, opportunities to rehearse procedures are limited, and the clinical educational outcomes prescribed by the Royal College of Anesthesiologists training curriculum 2021 are difficult to attain. Educational paradigms, such as mastery learning and dedicated practice, are increasingly being used to teach technical skills to enhance skills acquisition. Moreover, high-fidelity, resilient cadaver simulators are now available: the soft embalmed Thiel cadaver shows physical characteristics and functional alignment similar to those of patients. Tissue elasticity allows tissues to expand and relax, fluid to drain away, and hundreds of repeated injections to be tolerated without causing damage. Learning curves and their intra- and interindividual dynamics have not hitherto been measured on the Thiel cadaver simulator using the mastery learning and dedicated practice educational paradigm coupled with validated, quantitative metrics, such as checklists, eye tracking metrics, and self-rating scores.

OBJECTIVE

Our primary objective was to measure the learning slopes of the scanning and needling phases of an interscalene block conducted repeatedly on a soft embalmed Thiel cadaver over a 3-hour period of training.

METHODS

A total of 30 anesthesiologists, with a wide range of experience, conducted up to 60 ultrasound-guided interscalene blocks over 3 hours on the left side of 2 soft embalmed Thiel cadavers. The duration of the scanning and needling phases was defined as the time taken to perform all the steps correctly. The primary outcome was the best-fit linear slope of the log-log transformed time to complete each phase. Our secondary objectives were to measure preprocedural psychometrics, describe deviations from the learning slope, correlate scanning and needling phase data, characterize skills according to clinical grade, measure learning curves using objective eye gaze tracking and subjective self-rating measures, and use cluster analysis to categorize performance irrespective of grade.

RESULTS

The median (IQR; range) log-log learning slopes were -0.47 (-0.62 to -0.32; -0.96 to 0.30) and -0.23 (-0.34 to -0.19; -0.71 to 0.27) during the scanning and needling phases, respectively. Locally Weighted Scatterplot Smoother curves showed wide variability in within-participant performance. The learning slopes of the scanning and needling phases correlated: ρ=0.55 (0.23-0.76), P<.001, and ρ=-0.72 (-0.46 to -0.87), P<.001, respectively. Eye gaze fixation count and glance count during the scanning and needling phases best reflected block duration. Using clustering techniques, fixation count and glance were used to identify 4 distinct patterns of learning behavior.

CONCLUSIONS

We quantified learning slopes by log-log transformation of the time taken to complete the scanning and needling phases of interscalene blocks and identified intraindividual and interindividual patterns of variability.

Use of Ultrasound-Guided Interfascial Plane Blocks in Anterior and Lateral Thoracic Wall Region as Safe Method for Patient Anesthesia and Analgesia: Review of Techniques and Approaches during COVID-19 Pandemic

Ultrasound-guided interfascial plane blocks performed on the anterior and lateral thoracic wall have become an important adjuvant method to general anesthesia and an independent method of local anesthesia and pain management. These procedures diminish the harmful effects of anesthesia on respiratory function and reduce the risk of phrenic nerve paralysis or iatrogenic pneumothorax. In postoperative pain management, interfascial plane blocks decrease the dosage of intravenous drugs, including opioids. They can also eliminate the complications associated with general anesthesia when used as the sole method of anesthesia for surgical procedures. The following procedures are classified as interfascial plane blocks of the anterior and lateral thoracic wall: pectoral nerve plane block (PECS), serratus anterior plane block (SAP), transversus thoracic muscle plane block (TTP), pectoral interfascial plane block (PIF), and intercostal nerve block (ICNB). These blocks are widely used in emergency medicine, oncologic surgery, general surgery, thoracic surgery, cardiac surgery, orthopedics, cardiology, nephrology, oncology, palliative medicine, and pain medicine. Regional blocks are effective for analgesic treatment, both as an anesthesia procedure for surgery on the anterior and lateral thoracic wall and as an analgesic therapy after trauma or other conditions that induce pain in this area. In the era of the COVID-19 pandemic, ultrasound-guided interfascial plane blocks are safe alternatives for anesthesia in patients with symptoms of respiratory distress related to SARS-CoV-2 and appear to reduce the risk of COVID-19 infection among medical personnel.

Risk of Surgeon Contracting COVID-19 while Operating on COVID-19-Positive Patient, Impact of Safety Measures: Lessons Learnt

Introduction On March 11, 2020, the novel coronavirus disease 2019 (COVID-19) was declared as a pandemic. General surgeons provide care to COVID-19 positive patients requiring emergency surgeries and hence are exposed to the virus. Surgery on COVID-19-positive patient itself is a major risk factor for surgeon to contract COVID-19 infection. Noticeably, there is no data regarding number of surgeons who have contracted COVID-19 after operating on COVID-19-positive patients. Hence, the aim of this study was to find out the exact incidence of COVID-19 among surgeons operating on COVID-19-positive patients and to analyze the impact of safety measures practiced by us.

Methodology The study was conducted in a tertiary care center in Mumbai. It was a retrospective observational study with duration of 5 months from May 1, 2020, to September 30, 2020. Only those surgeons (faculty and resident doctors) were included who performed surgeries on COVID-19-positive patients (diagnosed by reverse-transcription polymerase chain reaction [RT-PCR] test) and gave consent for participation. As an institutional protocol, all patients undergoing surgery were tested by RT-PCR test (irrespective of chest X-ray or symptoms). Nasopharyngeal swabs for COVID-19 disease were collected prior to procedure but in some of these, results came after surgery. Still such patients were included in this study. Irrespective of COVID-19 status, same precautions were taken for all surgeries. The details of the patients like date of surgery, age, sex, surgery performed, duration of surgery, type of anesthesia used, and operating surgeon were noted from operation room (OR) register. Details of surgeons (faculty and resident doctors) who fulfilled inclusion criteria were noted by interview in terms of their demographic parameters, such as age, sex, designation, experience in years after completing postgraduation, comorbidities, whether they ever contracted COVID-19 (if yes, date), and safety measures practiced (yes, no, or cannot recollect). Patient was assumed to be the source only if the surgeon contracted COVID-19 within 14 days of surgery.

Results A total of 34 surgeons (7 faculty and 27 residents) conducted 41 surgeries on COVID-19-positive patients during the study period. All of them gave consent for participation in the study. More than one surgeon was involved in a particular surgery. Hence, there were 78 occasions (faculty during 16 occasions and resident doctors on 62 occasions) when surgeons were at risk to contract COVID-19 while operating on patients (n = 78). These surgeries had similar/comparable risk of COVID-19 exposure to surgeons and procedures with excessive exposure risk like airway procedures did not happen during the study period. The mean age of surgeon was 27.92 years (n = 78, standard deviation = 5.71) and median experience of faculty after completion of postgraduate degree was 7 years (n = 16, interquartile range [IQR] = 1.25–11.0). Only one faculty had comorbidity (diabetes mellitus). Duration of surgeries ranged from 50 to 420 minutes with median being 190 minutes (n = 41, IQR = 120–240). Only one surgeon (male faculty) contracted COVID-19 within 14 days of surgery (1.3% incidence, n = 78), a total of seven surgeons contracted COVID-19 during study period but not within 14 days of surgery (source other than patient operated) and all remaining surgeons were asymptomatic throughout the study period. The surgeon who contracted COVID-19 (within 14 days) performed surgery for 260 minutes and under general anesthesia. All the surgeons followed standard steps of donning and doffing, used personal protective equipment (PPE) body cover, shoe cover, hood, double pair of gloves, and N-95 masks at all times (n = 78). Intubation box was used in 100% cases of general anesthesia (n = 19). Fogging of OR after each surgery and interval of 20 minutes between surgeries was followed in 100% cases. Also, patient was wearing mask at all possible times and anesthetist and support staff used PPE during all surgeries. Hence the relationship between COVID-19 status and these safety measures cannot be assessed. Goggles and face shields were not used on 88.5% (n = 78) and 93.2% (n = 73, because five surgeons could not recollect whether they used face shields or not) occasions, respectively. Also, immediate shower after surgery was not taken on 93.6% occasions (n = 78). The surgeon who contracted COVID-19 had neither used goggles nor face shield. Also, he did not take shower immediately after surgery. However, there was no significant association between use of goggles, face shields, or shower after surgery and contraction of COVID-19 after operating patients (Fisher's exact p = 1.000). Air conditioner was switched-off only in 7.3% surgeries (n = 41). Smoke evacuator (cautery with attached suction) was not used in 97.6% cases. Clinical documentation (handling of patient's files) was done outside OR in only 17.1% surgeries (n = 41). However, there was no significant association between these safety measures and contraction of COVID-19 (Fisher's exact p = 1.000). General anesthesia was used in 19 surgeries (46.3%) while spinal anesthesia in 16 surgeries (39%), local anesthesia in 5 surgeries (12.2%), and total intravenous anesthesia (TIVA) in one surgery (2.4%). However, there was no significant association between type of anesthesia given during surgery and contraction of COVID-19 after operating on patients with Fisher's exact p-value of 1.000.

Conclusion Even though safety measures, like goggles, face shield, switching-off of air conditioner, use of smoke evacuator, and shower, immediately after surgery were not practiced in majority of cases, surgeon positivity rate was significantly less. Also, there was no use of negative pressure in OR. Hence, their significance becomes questionable. Although adopting all universal safety measures is in everyone's best interest, it is seldom cost-effective. To reduce resource exhaustion, especially in a pandemic situation, the use of various safety measures and staff must be balanced. Use and promotion of unnecessary safety measures leads to added health care costs and fear among health care workers in case of unavailability. Even though our study has a small sample size and has its own limitations, it can guide future studies to strengthen recommendations and reduce health care costs. This will also help in future epidemics/pandemics.

Intrapandemic regional anesthesia as practice: a historical cohort study in patients undergoing breast cancer surgery

BACKGROUND

The COVID-19 pandemic has markedly increased delays in oncologic surgeries because of the virus's impact on traditional anesthetic management. Novel protocols, developed to protect patients and medical professionals, have altered the ways and instances in which general anesthesia (GA) can be safely performed. To reduce virus exposure related to aerosol-generating procedures, it is now recommended to avoid GA when feasible and promote regional anesthesia instead. At our institution, we observed faster postoperative recovery in patients who received paravertebral blocks for breast cancer surgery instead of GA. This led us to formally evaluate whether regional anesthesia instead of GA helped improve time to hospital discharge.

METHODS

We conducted a historical cohort study to retrospectively analyze two cohorts of patients: prepandemic vs intrapandemic. We obtained approval from our institutional ethics committee to review files of consecutive patients who underwent breast cancer surgery between 30 March 2020 and 30 June 2020 (intrapandemic group; N = 106) and consecutive patients-moving backwards-from 28 February 2020 to 6 December 2019 (prepandemic group; N = 104). The primary outcome was the length of time between the end of surgery to readiness for hospital discharge. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), the need for postoperative analgesia, and the duration of stay in the postanesthesia care unit (PACU).

RESULTS

The median [interquartile range (IQR)] time to readiness for hospital discharge was significantly lower in patients who received paravertebral blocks for breast cancer surgery compared with GA (intrapandemic group, 119 [99-170] min vs prepandemic group, 191 [164-234] min; P < 0.001) as was the incidence of PONV (3% vs 11%; P = 0.03) and median [IQR] PACU durations of stay (29 [21-39] min vs 46 [37-63] min; P < 0.001).

CONCLUSIONS

Patients who received paravertebral blocks for breast cancer surgery in the intrapandemic group were ready for hospital discharge earlier, spent less time in the PACU, and experienced less PONV than those who received GA in the prepandemic group. With growing surgical wait times, concerns related to aerosol-generating procedures, and recommendations to avoid GA when feasible, paravertebral blocks as the principal anesthetic modality for breast cancer surgery offered benefits for patients and medical teams.

Anesthesia Considerations for Pregnant People With COVID-19 Infection

The purpose of this review is to describe updates following initial recommendations on best anesthesia practices for obstetric patients with coronavirus disease 2019. The first surge in the United States prompted anesthesiologists to adapt workflows and reconsider obstetric anesthesia care, with emphasis on avoidance of general anesthesia, the benefit of early neuraxial labor analgesia, and prevention of emergent cesarean delivery whenever possible. While workflows have changed to allow sustained safety for obstetric patients and health care workers, it is notable that obstetric anesthesia protocols for labor and delivery have not significantly evolved since the first coronavirus disease 2019 wave.

Obstetric analgesia and anaesthesia in SARS-CoV-2-positive parturients across 10 maternity units in the north-west of England: a retrospective cohort study

Since the start of the COVID‐19 pandemic, few studies have reported anaesthetic outcomes in parturients with SARS‐CoV‐2 infection. We reviewed the labour analgesic and anaesthetic interventions utilised in symptomatic and asymptomatic parturients who had a confirmed positive test for SARS‐CoV‐2 across 10 hospitals in the north‐west of England between 1 April 2020 and 31 May 2021. Primary outcomes analysed included the analgesic/anaesthetic technique utilised for labour and caesarean birth. Secondary outcomes included a comparison of maternal characteristics, caesarean birth rate, maternal critical care admission rate along with adverse composite neonatal outcomes. A positive SARS‐CoV‐2 test was recorded in 836 parturients with 263 (31.4%) reported to have symptoms of COVID‐19. Neuraxial labour analgesia was utilised in 104 (20.4%) of the 509 parturients who went on to have a vaginal birth. No differences in epidural analgesia rates were observed between symptomatic and asymptomatic parturients (OR 1.03, 95%CI 0.64–1.67; p = 0.90). The neuraxial anaesthesia rate in 310 parturients who underwent caesarean delivery was 94.2% (95%CI 90.6–96.0%). The rates of general anaesthesia were similar in symptomatic and asymptomatic parturients (6% vs. 5.7%; p = 0.52). Symptomatic parturients were more likely to be multiparous (OR 1.64, 95%CI 1.19–2.22; p = 0.002); of Asian ethnicity (OR 1.54, 1.04–2.28; p = 0.03); to deliver prematurely (OR 2.16, 95%CI 1.47–3.19; p = 0.001); have a higher caesarean birth rate (44.5% vs. 33.7%; OR 1.57, 95%CI 1.16–2.12; p = 0.008); and a higher critical care utilisation rate both pre‐ (8% vs. 0%, p = 0.001) and post‐delivery (11% vs. 3.5%; OR 3.43, 95%CI 1.83–6.52; p = 0.001). Eight neonates tested positive for SARS‐CoV‐2 while no differences in adverse composite neonatal outcomes were observed between those born to symptomatic and asymptomatic mothers (25.8% vs. 23.8%; OR 1.11, 95%CI 0.78–1.57; p = 0.55). In women with COVID‐19, non‐neuraxial analgesic regimens were commonly utilised for labour while neuraxial anaesthesia was employed for the majority of caesarean births. Symptomatic women with COVID‐19 are at increased risk of significant maternal morbidity including preterm birth, caesarean birth and peripartum critical care admission.

Evaluation of the Post-COVID Patient Prior to Elective Plastic Surgery: Developing an Evidence-Based Framework

Preoperative assessment of a potential surgical patient has long been a cornerstone of patient safety. As more patients get, and recover from, COVID-19, plastic surgeons will be faced with the challenge of evaluating the health status and operative risk of convalescent COVID patients who now desire elective surgery. A significant fraction of these patients, however, can have new or persistent health issues as a result of COVID-19, which can affect surgical safety. This paper briefly examines the current relevant literature regarding the post-COVID patient, reviews the waiting period for adequate recovery, and suggests an evidence-based framework for preoperative assessment, based on the severity of the prior COVID-19 episode, ongoing symptoms, and basic screening tests.

The practice of regional anesthesia during the COVID-19 pandemic: an international survey of members of three regional anesthesia societies

PURPOSE

To determine the preferences and attitudes of members of regional anesthesia societies during the COVID-19 pandemic.

METHODS

We distributed an electronic survey to members of the American Society of Regional Anesthesia and Pain Medicine, Regional Anaesthesia-UK, and the European Society of Regional Anaesthesia & Pain Therapy. A questionnaire consisting of 19 questions was developed by a panel of experienced regional anesthesiologists and distributed by email to the participants. The survey covered the following domains: participant information, practice settings, preference for the type of anesthetic technique, the use of personal protective equipment, and oxygen therapy.

RESULTS

The survey was completed by 729 participants from 73 different countries, with a response rate of 20.1% (729/3,630) for the number of emails opened and 8.5% (729/8,572) for the number of emails sent. Most respondents (87.7%) identified as anesthesia staff (faculty or consultant) and practiced obstetric and non-obstetric anesthesia (55.3%). The practice of regional anesthesia either expanded or remained the same, with only 2% of respondents decreasing their use compared with the pre-pandemic period. The top reasons for an increase in the use of regional anesthesia was to reduce the need for an aerosol-generating medical procedure and to reduce the risk of possible complications to patients. The most common reason for decreased use of regional anesthesia was the risk of urgent conversion to general anesthesia. Approximately 70% of the responders used airborne precautions when providing care to a patient under regional anesthesia. The most common oxygen delivery method was nasal prongs (cannula) with a surgical mask layered over it (61%).

CONCLUSIONS

Given the perceived benefits of regional over general anesthesia, approximately half of the members of three regional anesthesia societies seem to have expanded their use of regional anesthesia techniques during the initial surge of the COVID-19 pandemic.

Removal of a Giant Cyst of the Left Ovary from a Pregnant Woman in the First Trimester by Laparoscopic Surgery under Spinal Anesthesia during the COVID-19 Pandemic

This paper reports a case of a 21 year old primigravida at 6 weeks gestation, suffering from important abdominal pain, who was admitted into the medical center with a giant cyst of 28 × 20 cm on her left ovary. A torsion of the ovarian cyst was suspected. Her COVID-19 status was unknown. In view of the emergency of the situation and the COVID-19 pandemic, laparoscopy in spinal anesthesia was performed. The patient remained conscious during the surgical intervention and tolerated it well apart from a slight dyspnea, which was easily eliminated by changing her body position and decreasing the pneumoperitoneum pressure. The ovarian cyst was removed by enlarging the trocar incision. The patient recovered with neither incident nor pregnancy loss. COVID-19-related complications can induce adverse pregnancy outcomes. Under general anesthesia, patients with COVID-19 are at risk of severe pneumonia and of passing their infection to the medical personnel. To avoid such complications in non-specialized centers, laparoscopy should be performed in regional anesthesia. Laparoscopy in spinal anesthesia can be performed safely on pregnant patients by placing them in the proper position, using a low pneumoperitoneum, and monitoring the hemodynamics. During early pregnancy, general anesthesia induces a higher risk of teratogenic effects and of miscarriage.

Impact of COVID-19 on Neurosurgery in Brazil's Health System: The Reality of a Developing Country Affected by the Pandemic

BACKGROUND

The coronavirus disease identified in 2019 (COVID-19) pandemic changed neurosurgery protocols to provide ongoing care for patients while ensuring the safety of health care workers. In Brazil, the rapid spread of the disease led to new challenges in the health system. Neurooncology practice was one of the most affected by the pandemic due to restricted elective procedures and new triage protocols. We aim to characterize the impact of the pandemic on neurosurgery in Brazil.

METHODS

We analyzed 112 different types of neurosurgical procedures, with special detail in 11 neurooncology procedures, listed in the Brazilian Hospital Information System records in the DATASUS database between February and July 2019 and the same period in 2020. Linear regression and paired t-test analyses were performed and considered statistically significant at P < 0.05.

RESULTS

There was an overall decrease of 21.5% (28,858 cases) in all neurosurgical procedures, impacting patients needing elective procedures (-42.46%) more than emergency surgery (-5.93%). Neurooncology procedures decreased by 14.89%. Nonetheless, the mortality rate during hospitalization increased by 21.26%. Linear regression analysis in hospitalizations (Slope = 0.9912 ± 0.07431; CI [95%] = 0.8231-1.159) and total cost (Slope = 1.03 ± 0.03501; CI [95%] = 0.9511-1.109) in the 11 different types of neurooncology procedures showed a P < 0.0001. The mean cost per type of procedure showed an 11.59% increase (P = 0.0172) between 2019 and 2020.

CONCLUSIONS

The COVID-19 pandemic has increased mortality, decreased hospitalizations, and therefore decreased overall costs, despite increased costs per procedure for a variety of neurosurgical procedures. Our study serves as a stark example of the effect of the pandemic on neurosurgical care in settings of limited resources and access to care.

Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic

BACKGROUND

laparoscopic surgery is mainly performed in general anesthesia. Symptomatic patients infected with COVID-19 needing surgery are however at higher risk for COVID-19 complications in general anesthesia than in regional anesthesia. Even so, Covid transfection is a hazard to medical personnel during the intubation procedure and treatment drugs may be in shortage during a pandemic. Recovery and hospital stay are also shorter after laparoscopy. Laparoscopy performed in regional anesthesia may have several advantages in limiting Covid.

METHODS

international literature on the risk of COVID-19 complications development was searched. 3 topics concerning laparoscopic surgery were reviewed: (1) Achievements in laparoscopy; (2) Advantages of regional anesthesia compared to general anesthesia; (3) Feasibility to perform laparoscopy in regional anesthesia in COVID-19 pandemic. The authors reviewed abstracts and full-text articles concerning laparoscopic surgery, gynecology, anesthesia and COVID-19. Studies published in PubMed, Embase, Cochrane Library and found in Google Scholar before 1st FEB, 2021 were retrieved and analyzed.

RESULTS

a total of 83 studies were found, all of them written in English. 17 studies could be found in gynecology and in general surgery about laparoscopy with regional anesthesia. In Covid time only one study compared laparoscopic surgery in general anesthesia to laparotomy and another study laparotomy in general anesthesia to regional anesthesia. Laparoscopy showed no disadvantage compared to laparotomy in Covid pandemic and in another study laparotomy in general anesthesia was associated with higher mortality and more pulmonary complications. Trendelenburg position can be a threat if used by inexperienced personnel and can induce unintended anesthesia of breathing organs. On the other hand Trendelenburg position has advantages for cardiovascular and pulmonary functions. Pneumoperitoneum of low CO2 pressure is well tolerated by patients.

CONCLUSIONS

elective surgery should be postponed in symptomatic Covid patients. In inevitable emergency surgery intubation anesthesia in COVID-19 pandemic is as far as possible to be avoided. In COVID-19 pandemic, regional anesthesia is the preferred choice. The optimum may be the combination of laparoscopic surgery with regional anesthesia. Reducing the pneumoperitoneum is a good compromise for the comfort of patients and surgeons. A special case is gynecology, which needs to be performed in Trendelenburg position to free pelvic organs.

Ultrasound-guided regional anesthesia in COVID-19 and future pandemics: infection control

PURPOSE OF REVIEW

Infection control is inherent in ultrasound-guided regional anesthesia practice, because ultrasound transducer and coupling gel can be vectors for pathogen transmission. We reviewed the current standards and recommendations of ultrasound transducer cleaning, disinfection, and safe handling of ultrasound equipment. Based on the available data, we propose a set of practical recommendations applicable to coronavirus disease 2019 (COVID-19) pandemic and future epidemics.

RECENT FINDINGS

Regional anesthesia is often preferred over general anesthesia for COVID-19 patients. Avoidance of general anesthesia reduces the need for aerosol generating procedures. Administration of ultrasound-guided regional anesthesia and surgery under regional anesthesia in COVID-19 patients requires careful infectious precautions to prevent the viral spread through the use equipment.

SUMMARY

Ultrasound machine, transducer and coupling gel can serve as a vector for transmission of pathogens. In the era of COVID-19 pandemic, standardized strategies are recommended to minimize the risk of spread of COVID-19 to both patients and the healthcare providers.

Regional anesthesia in coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

Coronavirus disease 19 (COVID-19) has presented numerous challenges to healthcare systems worldwide. The virus is highly contagious and infectious since transmission can occur via multiple routes. General measures to prevent viral transmission to patients and healthcare personnel, such as a reduction in clinical load and routine testing, must be coupled with multiple additional safety measures in perioperative services.

RECENT FINDINGS

Regional anesthesia preserves respiratory function and reduces aerosol-generating procedures typically associated with airway management in general anesthesia, making it the first choice for a suspected or confirmed COVID-19 patient in need of surgery with anesthesia. A well thought out regional anesthetic plan, implementation of hygiene and (personal) safety measures are necessary to ensure the best possible outcome for both the patient and the healthcare staff.

SUMMARY

The present review addresses both practical and recommended measures for performing regional anesthesia in the pandemic, to ensure patient and staff safety, and equipment protection. Further research and evidence-based guidelines are necessary to devise an established standard of care during the current COVID-19 and possible future pandemics.

Recommendations for developing clinical care protocols during pandemics: From theory and practice

In 2019, a novel coronavirus called the severe acute respiratory syndrome coronavirus 2 led to the outbreak of the coronavirus disease 2019, which was deemed a pandemic by the World Health Organization in March 2020. Owing to the accelerated rate of mortality and utilization of hospital resources, health care systems had to adapt to these major changes. This affected patient care across all disciplines and specifically within the perioperative services. In this review, we discuss the strategies and pitfalls of how perioperative services in a large academic medical center responded to the initial onset of a pandemic, adjustments made to airway management and anesthesia specialty services – including critical care medicine, obstetric anesthesiology, and cardiac anesthesiology - and strategies for reopening surgical caseload during the pandemic.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled.

The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Awake Regional Anesthesia for Upper Limb Orthopedic Surgery During the COVID-19 Pandemic

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19 illness, is mainly transmitted because of close contact with respiratory droplets and airborne particles. Aerosol-generating procedures during general anesthesia can increase the risk of COVID-19 transmission. An effective alternative to general anesthesia for upper limb orthopedic surgery is regional anesthesia (RA) using brachial plexus block.

Materials and Methods:

Seventy-eight patients who received a brachial plexus block for upper limb trauma and elective operations before and during the COVID-19 pandemic, from 2017 to 2020, were included in this study. A protocol was devised for patient positioning, draping and equipment positioning for each location group—shoulder and upper arm; elbow and forearm; and distal extremities.

Results:

RA was effective for upper limb surgery in 77 of 78 (98.7%) patients. Sixty-five patients (83.3%) were discharged the same day, with the average time from leaving the operating theater to discharge from hospital of 2.8 hours. No postoperative complications were recorded, and no patient nor staff member contracted COVID-19 infection 2 weeks after the operation.

Conclusion:

We demonstrate the efficacy of awake RA for upper limb orthopedic procedures. We share our tips and tricks for implementing this into clinical practice and discuss the specific advantages of RA in the context of the COVID-19 global pandemic.

Awake Spinal Fusion

»

Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints.

»

ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia.

»

The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

The effect of the COVID-19 pandemic on orthopedic surgeries in a tertiary referral center

Objectives

The aim of this study is to investigate the effect of the novel coronavirus-2019 (COVID-19) pandemic on the operational trends in the orthopedic surgery department of a tertiary referral center.

Patients and methods

A total of 305 orthopedic surgical procedures in 245 patients (136 males, 109 females; mean age: 34±26.6 years; range, 0 to 91 years) between March 16^th and June 27^th, 2020 were retrospectively analyzed. The same period of the year before including 860 procedures in 783 patients (364 males, 419 females; mean age: 33.6±25.8 years; range, 0 to 95 years) was also reviewed as a pre-pandemic control group. Patient demographics, surgical indications, COVID-19 polymerase chain reaction (PCR) test status, method of anesthesia, surgical subspecialties (trauma, sports, etc.), trauma mechanisms, and surgical priorities were evaluated. The pandemic and the pre- pandemic periods were compared.

Results

The rate of elective surgeries decreased compared to the previous year, and priority C type surgeries had the highest frequency (42.5%). Orthopedic trauma was the leading subspecialty with 91 (29.8%) cases and had a higher share, compared to the pre-pandemic period (17.0%). Hip fractures (18.7%) were the most common cause of trauma surgery, and simple falls (42.3%) composed the largest group of trauma mechanisms, which was similar to the pre-pandemic period (hip fractures, 13.6%; simple falls, 42.5%). The distribution of surgical urgency levels and subspecialties differed significantly between the pre-pandemic and pandemic periods (p<0.001). Post- hoc analysis of subspecialty distribution revealed a significant decrease in arthroplasty (p=0.002) and hand surgery (p<0.001), and a significant increase in trauma (p<0.001) and the “other” category (p<0.001).

Conclusion

Our experience in a tertiary referral center illustrated a shift toward performing emergent and urgent surgeries, when the severity of the outbreak increased. Prioritizing surgical urgencies during the outbreak changed the orthopedic surgery practice with an emphasis on trauma and oncology surgeries. Hip fractures were the most common cause of trauma surgery, and simple falls composed the largest group of trauma mechanisms.

Management of maternal COVID-19: considerations for anesthesiologists

PURPOSE OF REVIEW

To describe updates to pragmatic recommendations that were published during the first coronavirus disease 2019 (COVID-19) surge, including the current thinking about whether pregnancy worsens the severity of COVID-19.

RECENT FINDINGS

Although a majority of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain asymptomatic or paucisymptomatic, pregnancy puts women at higher risk of severe COVID-19 and adverse birth outcomes. Pregnant and recently pregnant women are more likely to be admitted to intensive care units and receive mechanical ventilation than nonpregnant patients with COVID-19, although preexisting maternal comorbidities are significant risk factors.Early provision of neuraxial labor analgesia with a functional indwelling epidural catheter has been universally promoted, with the goal to reduce avoidable general anesthesia for cesarean delivery and mitigate risks for healthcare workers during airway manipulation. This recommendation, along with updated workflow models of anesthesia coverage, may contribute to a reduction in general anesthesia rates.

SUMMARY

Initial recommendations to provide early neuraxial labor analgesia and avoid general anesthesia for cesarean delivery have not changed over time. Although workflows have significantly changed to allow continued patient and healthcare workers' safety, clinical anesthesia protocols for labor and delivery are essentially the same.

Treatment management of COVID-19 positive patients with renal colic secondary to distal ureteral stone

OBJECTIVE

In this study, we aimed to contribute to the literature by sharing and evaluating the clinical characteristics and our treatment and follow-up approaches in patients in the COVID-19 positive treatment process who had presented to our hospital's emergency department with a distal ureteral stone and to examine the effects of the pandemic and disease in this group of patients.

METHOD

The study included 14 patients infected with COVID-19 who had presented to the Erzurum City Hospital Emergency Department between August 2020 and December 2020 with the complaint of renal colic in which distal ureteral stones were detected in the tests. The demographic and clinical characteristics of patients, laboratory and radiological examinations, characteristics of ureteral stones, details of treatments applied to patients, treatment procedures of patients who had undergone surgical treatment, patient files, visit and operation notes and the patient discharge reports were retrospectively reviewed and evaluated.

RESULTS

The study included 14 patients. The average age of the patients was 35.7 (±14.35). The average stone size was 6.2 (±1.8) mm. Analgesic treatment and MET for distal ureteral stones were begun in 11 (78.6%) of the patients. Pain control was achieved in nine patients (64.2%) with analgesic treatment and MET, and the stone was removed without invasive intervention. Surgical intervention was performed in a total of five patients (35.7%).

CONCLUSION

In most COVID-19 infected patients with renal colic and a distal ureteral stone, results can be obtained using MET. Patients with a distal ureteral stone and persistent renal colic can be safely and effectively treated by endoscopic ureteral stone treatment after taking necessary precautions. Prospective, randomised, and controlled studies are required on this subject.

Rational Use of Oxygen in COVID-19 Pandemic - Are We Doing Enough?

During the episodes of large case surge of COVID-19, the health care system of many nations have struggled, more so in nations with resource limitations. Recently, Nepal and the neighboring nation India are being hit hard by the pandemic. Management of patients with moderate and severe COVID-19 remains largely supportive, with oxygen therapy being the cornerstone of the management. Procurement, maintenance of oxygen supply system, coupled with avoiding misuse and wastage of oxygen is of paramount importance to better utilize the scarce resources amidst the peaks of a pandemic. Nepal needs to adopt policies to make best use of its oxygen stores and supplies with a collective effort from all stakeholders to save additional lives.

Validation of the soft-embalmed Thiel cadaver as a high-fidelity simulator of pressure during targeted nerve injection

INTRODUCTION

Although administration of regional anesthesia nerve blocks has increased during the COVID-19 pandemic, training opportunities in regional anesthesia have reduced. Simulation training may enhance skills, but simulators must be accurate enough for trainees to engage in a realistic way-for example, detection of excessive injection pressure. The soft-embalmed Thiel cadaver is a life-like, durable simulator that is used for dedicated practice and mastery learning training in regional anesthesia. We hypothesized that injection opening pressure in perineural tissue, at epineurium and in subepineurium were similar to opening pressures measured in experimental animals, fresh frozen cadavers, glycol soft-fix cadavers and patients.

METHODS

We systematically reviewed historical data, then conducted three validation studies delivering a 0.5 mL hydrolocation bolus of embalming fluid and recording injection pressure. First, we delivered the bolus at 12 mL/min at epimysium, perineural tissue, epineurium and in subepineurium at 48 peripheral nerve sites on three cadavers. Second, we delivered the bolus at using three infusion rates: 1 mL/min, 6 mL/min and 12 mL/min on epineurium at 70 peripheral nerve sites on five cadavers. Third, we repeated three injections (12 mL/min) at 24 epineural sites over the median and sciatic nerves of three cadavers.

RESULTS

Mean (95%) injection pressure was greater at epineurium compared with subepineurium (geometric ratio 1.2 (95% CI: 0.9 to 1.6)), p=0.04, and perineural tissue (geometric ratio 5.1 (95% CI: 3.7 to 7.0)), p<0.0001. Mean (95%) injection pressure was greater at 12 mL/min compared with 1 mL/min (geometric ratio 1.6 (95% CI: 1.2 to 2.1), p=0.005). Pressure measurements were similar in study 3 (p>0.05 for all comparisons).

DISCUSSION

We conclude that the soft-embalmed Thiel cadaver is a realistic simulator of injection opening pressure.

Decision-to-delivery interval and neonatal outcomes for category-1 caesarean sections during the COVID-19 pandemic

General anaesthesia is known to achieve the shortest decision‐to‐delivery interval for category‐1 caesarean section. We investigated whether the COVID‐19 pandemic affected the decision‐to delivery interval and influenced neonatal outcomes in patients who underwent category‐1 caesarean section. Records of 562 patients who underwent emergency caesarean section between 1 April 2019 and 1 July 2019 in seven UK hospitals (pre‐COVID‐19 group) were compared with 577 emergency caesarean sections performed during the same period during the COVID‐19 pandemic (1 April 2020–1 July 2020) (post‐COVID‐19 group). Primary outcome measures were: decision‐to‐delivery interval; number of caesarean sections achieving decision‐to‐delivery interval < 30 min; and a composite of adverse neonatal outcomes (Apgar 5‐min score < 7, umbilical arterial pH < 7.10, neonatal intensive care unit admission and stillbirth). The use of general anaesthesia decreased significantly between the pre‐ and post‐COVID‐19 groups (risk ratio 0.48 (95%CI 0.37–0.62); p < 0.0001). Compared with the pre‐COVID‐19 group, the post‐COVID‐19 group had an increase in median (IQR [range]) decision‐to‐delivery interval (26 (18–32 [4–124]) min vs. 27 (20–33 [3–102]) min; p = 0.043) and a decrease in the number of caesarean sections meeting the decision‐to‐delivery interval target of < 30 min (374/562 (66.5%) vs. 349/577 (60.5%); p = 0.02). The incidence of adverse neonatal outcomes was similar in the pre‐ and post‐COVID‐19 groups (140/568 (24.6%) vs. 140/583 (24.0%), respectively; p = 0.85). The small increase in decision‐to‐delivery interval observed during the COVID‐19 pandemic did not adversely affect neonatal outcomes.