Anesthesia Alert: Safe Anesthesia Care During COVID-19

Anesthesia providers have been forced to alter the way they work in order to deliver safe and efficient care during the COVID-19 pandemic. Because of their close proximity to patients and the types of procedures they perform, anesthesia professionals are among the providers most at risk of exposure to the coronavirus. Fortunately, several straight-forward interventions can reduce transmission risks.

The science continues to evolve, but experts believe COVID-19 is predominantly transmitted by droplet spread and through direct contact. Early research indicates that the highest viral load appears in sputum and upper airway secretions. Anesthesia providers are positioned near the patient's head, and many procedures they perform are aerosol-generating. High-flow oxygen delivery, endotracheal intubation and extubation, non-invasive ventilation and open suctioning of airways all can generate droplets. Not surprisingly, guidance to help mitigate risk associated with airway management centers on avoiding aerosol-generating procedures whenever possible. Current professional society recommendations include:

• Focus on "safe, accurate and swift" airway management techniques. ?Multiple attempts to secure an airway can increase exposure. Ensure airway devices are easy to use, so endotracheal tubes can be placed on the first try.
• Use suitable alternatives to aerosol-generating procedures, whenever possible.
• Keep as safe a distance as possible from the patient's airway while maintaining appropriate technique.
• Use airway management tools and techniques that lessen the need for prolonged direct patient contact, which can occur with chin lift and jaw thrust maneuvers.
• Opt for single-use equipment instead of reusable devices, when feasible.

Placing (intubating) or removing (extubating) an endotracheal tube can cause patients to cough. Research indicates these aerosol-generating procedures increase the odds of transmitting an acute respiratory infection to the surgical team by six-fold.

The Anesthesia Patient Safety Foundation (APSF) recommends distancing in the post-anesthesia care unit from patients who are coughing or sneezing repeatedly due to airway irritation. These patients might require an enclosed room with limited personnel who practice full airborne precautions, according to the APSF. Of course, many outpatient surgery facilities have limited space available to allocate for this kind of use. The recommendation, though, underscores the importance of reducing patient coughing to the extent possible. A practice that may help stem patient coughing in the OR or recovery unit is pulling the endotracheal tube or extubating while the patient is still asleep in the OR. By replacing the endotracheal tube with a less invasive device, coughing can be limited as the patient emerges from anesthesia. One such option is a pharyngeal airway device with tubing long enough to stent open the airway, but short enough that coughing and gagging are reduced when it is removed from a waking patient. This type of airway management tool also can maintain a patient airway without the need for a chin lift or jaw thrust, reducing prolonged patient-provider contact.

During the administration of general anesthesia, oxygen is supplied through the anesthesia gas machine circuit that connects either to a mask, laryngeal mask airway (LMA) or endotracheal tube. Air leakage around a mask or LMA with positive pressure ventilation, along with the process of intubating and extubating, can increase viral spread and surgical team exposure.

The type of oxygen delivery and flow rate determines the possibility of aerosol generation and how far droplets travel. Oxygen delivery modes depend on the procedure and anesthesia depth, which ranges from minimal sedation to general anesthesia. Sedation anesthesia typically involves delivering oxygen through nasal cannula, an oxygen mask or pharyngeal airway device. When nasal cannulas are the oxygen source, the patient's nose and mouth are completely uncovered and exposed. Droplets in exhaled air jets can result in potentially infectious aerosols. To help prevent airborne pathogen spread, patients using nasal cannulas should wear a surgical mask when practical. With any oxygen delivery device, oxygen flow rates should be kept to the lowest possible levels to maintain saturation while minimizing aerosol spread.

Masks developed for certain procedures can be helpful, too. In the endoscopy suite, for example, a mask created for endoscopic procedures features a port that accommodates the endoscope. The mask enables higher FiO2 delivery, while serving as a simple barrier. Oxygen face masks can help act as a mechanical barrier when patients cough or sneeze.

Another recommendation from the American Society of Regional Anesthesia and Pain Medicine suggests using regional anesthesia rather than general anesthesia given the high risk of aerosol generation during administration of the latter. Regional anesthesia with deep sedation provides patient comfort and depression of consciousness while preserving spontaneous ventilation. Regional anesthesia and sedation/monitored anesthesia care (MAC) are associated with lower risk of postoperative complications than general anesthesia. With any MAC, anesthesia providers must have the appropriate PPE available if an unsuccessful anesthetic quickly requires converting to a general anesthetic. Keeping the patient safe and comfortable while minimizing risk is an appropriate goal.

No one knows which COVID-driven practices will continue after the pandemic ceases to be at the forefront of our thinking. Today, though, anesthesia providers and their clinical colleagues can do a great deal to help mitigate the spread of COVID-19 when caring for surgical patients. With procedures continuing across the country and the U.S. heading into the respiratory illness season of colds, flus and COVID-19, now is a good time to implement and refine practices that might not have been applied in the early months of the pandemic. As we learn more, we can provide safer and better care — together. OSM