Urgent Surgery on Covid Positive Patient

[BLADEMDA]

I have come across this situation several times. The patient is Covid positive but requires surgery with anesthesia. How do you all get consent? Do you explain the increased risk of GA? Do any of you do Regional these days on Covid positive? Let's say they are mildly symptomatic does that change your approach or consent? What if they are asymptomatic do you discuss any increased risk of GA?

Should the fracture even be fixed on these patients? If so, what time frame? Should the case be delayed by a week? All comments are appreciated.

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[BLADEMDA]

A recent publication in The Lancet by Covidsurg demonstrates that more than half of the COVID-19-positive patients undergoing surgery had a pulmonary complication in the 30 days following the procedure. Nearly 24 percent of these patients died.

Covidsurg researchers also found that men, patients older than 70 and those with multiple medical problems were more likely to have poor outcomes.

Covidsurg, a research collaborative that is part of the National Institute for Health Research, includes surgeons and anesthesiologists from more than 69 countries. It was formed at the start of the COVID-19 pandemic with the goal to conduct international research to examine the impact that the virus has on surgical practice patterns worldwide, as well as the safety of operating on patients with COVID-19.

 

[BLADEMDA]

Mortality in patients with SARS-CoV-2 was mainly in those who had postoperative pulmonary complications, which was about 50% of patients. This rate is far higher than the pre-pandemic baseline; in the POPULAR multicentre, prospective, observational study of 211 hospitals from 28 European countries in 2014–15, the pulmonary complication rate was 8%.5

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication ...

www.ncbi.nlm.nih.gov

 

[BLADEMDA]

https://bjanaesthesia.org/article/S0007-0912(20)30372-X/pdf

 

[coffeebythelake]

A recent publication in The Lancet by Covidsurg demonstrates that more than half of the COVID-19-positive patients undergoing surgery had a pulmonary complication in the 30 days following the procedure. Nearly 24 percent of these patients died.

Covidsurg researchers also found that men, patients older than 70 and those with multiple medical problems were more likely to have poor outcomes.

Covidsurg, a research collaborative that is part of the National Institute for Health Research, includes surgeons and anesthesiologists from more than 69 countries. It was formed at the start of the COVID-19 pandemic with the goal to conduct international research to examine the impact that the virus has on surgical practice patterns worldwide, as well as the safety of operating on patients with COVID-19.

But does that reflect the natural course of thr COVID infection, or is this added risk from anesthetizing the patient? Does thr fact these COVID patients require urgent or emergency surgery simply mean they are sicker to begin with?

I would try to avoid general anesthesia to minimize aerosol generation. For an orthopedic case that would mean performing regional anesthesia if viable. If there is no other option I would GA and reverse with sugammadex at end or case to ensure 100% muscle strength. I dont think there js data on whether specific anesthetic drugs make a difference (gas vs TIVA), etc.

Would have full PPE / N95 / negative pressure room and COVID workflow to minimize exposure of OR and outside-of-OR staff (e.g., direct from patient room to OR bypassing preop holding and PACU). Although minimizing number of staff in OR, this kind of workflow is still a huge resource sink. But overall I'm more worried about COVID exposure to others.

Also want to mention that ASA / APSF released a joint statement about recommended time for elective surgery after COVID to minimize pulmonary complications. Of course the situation is different than what you describe. ELECTIVE and AFTER COVID.

 

[WholeLottaGame7]

I have come across this situation several times. The patient is Covid positive but requires surgery with anesthesia. How do you all get consent? From the patient if they're capable, from a family member if not. Usually call into the room or get in touch with RN if they're in there. If have to do in person, can get right before you roll to OR. Do you explain the increased risk of GA? Yes. Do any of you do Regional these days on Covid positive? Mostly peds, but I would if able. Let's say they are mildly symptomatic does that change your approach or consent? No. What if they are asymptomatic do you discuss any increased risk of GA? Yes.

Should the fracture even be fixed on these patients? If so, what time frame? Should the case be delayed by a week? All comments are appreciated.

Answers above. Oftentimes the asymptomatic patients seem to do OK with GA, but you never know a priori who's going to misbehave and who isn't. Would certainly have the conversation about pulmonary complications regardless.

 

[IlDestriero]

I’ve discussed that there may be unknowable complications as a result of being Covid + or having had a recent infection and that there is nothing we can do to alter that risk, but the risk of not doing the emergent surgery is likely much larger. I write, “Discussed possible increased risks 2/2 Covid status.”

 

[GassYous]

My understanding is that most fractures should be fixed within at least a week max and that if you want to wait for an elective case in a covid+, it's better to wait at least 5-6 weeks. So if it's urgent I'd rather just do it now, tube and leave them intubated in the icu so they can have a little more time to recover. I'd rather not mess around with pneumothorax from a brachial plexus block or line or any other pulmonary issue if I can avoid it because I've seen how quickly these guys can desat and crump.

 

[dabears505]

What produces more aerosols? Placing an lma or them sedated and coughing?

 

[GassYous]

What produces more aerosols? Placing an lma or them sedated and coughing?

I don't know the answer but a lot of the time I leave the facemask on below the oxygen mask.

 

[BLADEMDA]

Would most of you prefer a Regional technique over a GA in an asymptomatic patient? What if the patient is symptomatic and coughing? Would you prefer an ETT in that situation?

We don't really have enough data or evidence to show if anesthesia technique even makes a difference in outcome.

 

[nimbus]

We generally don’t delay fracture care for asymptomatic COVID.

No forced air warming though.

44 Kaiser hospital staff members infected in COVID-19 outbreak, 1 worker dies

A worker in the emergency department at Kaiser Permanente San Jose (Calif. ) Medical Center has died after a COVID-19 outbreak in which 44 staff members were infected, hospital officials told NBC Bay Area Jan. 3.

www.beckershospitalreview.com

 

[abolt18]

Lots of epidurals and c-sections on COVID+ parturients. Some asymptomatic, some coughing up copious amounts of thick sputum. Thankfully haven't seen any maternal mortality from it all.

 

[DrZzZz]

If the case is doable with regional, that's been our route to avoid airway manipulation, symptoms or not. If the case requires GA, tube 100%. Also, all upper endoscopies get tubes. Haven't had to do a TEE on a Covid patient (can't think of a scenario where you'd have to do one), but that would also get a tube if we were forced into that. Extubation criteria don't really change, though if there's any question about extubating at the end, low threshold to leave the tube and send em to the ICU.

 

[FiO2@21]

We generally don’t delay fracture care for asymptomatic COVID.

No forced air warming though.

44 Kaiser hospital staff members infected in COVID-19 outbreak, 1 worker dies

A worker in the emergency department at Kaiser Permanente San Jose (Calif. ) Medical Center has died after a COVID-19 outbreak in which 44 staff members were infected, hospital officials told NBC Bay Area Jan. 3.

www.beckershospitalreview.com

Well that's horrible

 

[chessknt]

I have come across this situation several times. The patient is Covid positive but requires surgery with anesthesia. How do you all get consent? Do you explain the increased risk of GA? Do any of you do Regional these days on Covid positive? Let's say they are mildly symptomatic does that change your approach or consent? What if they are asymptomatic do you discuss any increased risk of GA?

Should the fracture even be fixed on these patients? If so, what time frame? Should the case be delayed by a week? All comments are appreciated.

Do they have infiltrates or is it incidental positive no pulmonary disease? If the latter do you have a second negative test to know if this is an acute infection or old positive?

A lot of variations I would think...

 

[GassYous]

We generally don’t delay fracture care for asymptomatic COVID.

No forced air warming though.

44 Kaiser hospital staff members infected in COVID-19 outbreak, 1 worker dies

A worker in the emergency department at Kaiser Permanente San Jose (Calif. ) Medical Center has died after a COVID-19 outbreak in which 44 staff members were infected, hospital officials told NBC Bay Area Jan. 3.

www.beckershospitalreview.com

Well as we all know, santas are essential workers and deserve early access to vaccines

https://twitter.com/i/events/1320722084390195200

 

[Volatile]

If they are covid positive I generally just give a quick mention of potential pulm complications, although I have yet to have any issues (admittedly these patient have been either asymptomatic or mild symptoms). I feel like I take 1 covid patient to the OR every week, I sit my own cases, have done GA, sedation, blocks. I find myself preferring Mac and regional now if able, I just put their N95 over the nasal cannula and roll. I will mention I’ve already had covid, was asymptomatic, and have had so many exposures without issue I’ve sorta stopped caring :/
Do whatever you’re comfortable with, there’s no right answer

 

[coffeebythelake]

Would most of you prefer a Regional technique over a GA in an asymptomatic patient? What if the patient is symptomatic and coughing? Would you prefer an ETT in that situation?

We don't really have enough data or evidence to show if anesthesia technique even makes a difference in outcome.

If symptomatic and coughing, I would make sure they have a mask on and would just stand further away from thr patient...

whereas when u do GA you must be up in their face being blasted by covid aerosols

 

[Shimmy8]

We do them every day.

If it’s endo or GA we tube 100%. None of our surgeons for these cases really like regional, so that’s rare anyway. Haven’t seen anything with regard to complications from asymptomatic patients post op, but then again will we really know how they are 1-2 weeks out?

Just consent as above that this is new and there are potential unknown future issues but we need to proceed with an urgent/emergent case. Most patients/families just want the current issue addressed (surgery).