Perioperative management of post-COVID-19 surgical patients: ISA National Advisory
The Indian Society of Anaesthesiologists (ISA) has issue advisory and position statement pertaining to the perioperative management of post-severe acute respiratory syndrome COVID-19 in surgical patients. After recession of second wave of COVID-19 a number of patients who have recovered from the disease are reporting for elective/emergency surgery either for primary ailment or for a complication arising from COVID-19, such as mucormycosis.
The present guidelines will provide protocols regarding the perioperative management, morbidity and mortality of COVID-19-recovered patients. The position statement and advisory aims to guidr the anaesthesiologists in the safe perioperative management of the post-COVID-19 surgical patient population.
The present ISA advisory and position statement is subject to change and updation in the coming days as latest information pours in.
The ISA advisory and position statement has been published in the Indian journal of Anesthesia.
ISA POSITION STATEMENT
1.SARS-CoV-2 infection primarily affects the pulmonary and cardiac systems but has the potential for involvement of multiple systems with both short-and long-term sequelae. Post-COVID syndrome can include symptoms related to residual inflammation, organ damage, impact on pre-existing health conditions, non-specific effects due to hospitalisation or prolonged ventilation (post-intensive care syndrome). The patients can be on polypharmacy, including steroids and anticoagulants. All these factors can have significant implications, which make the perioperative management of post-COVID-19 patients challenging.
2. Physiological impairment and radiological features of pulmonary fibrosis and interstitial lung disease (ILD) with impaired diffusion and decreased functional capacity have been observed in cohorts of patients followed for 3–6 months after recovery from SARS-CoV-2 infection.
3. Elevated serum cardiac troponin levels, asymptomatic cardiac arrhythmias, or abnormalities in cardiac imaging may be the only cardiovascular post-COVID-19 manifestations. These patients are at an increased risk of left ventricular diastolic/systolic dysfunction, pulmonary arterial hypertension, heart failure, fresh myocardial infarction and arrhythmias, including premature ventricular complexes, ventricular tachyarrhythmias and atrial fibrillation due to healing myocarditis and myocardial fibrosis. Inappropriate sinus tachycardia or bradycardia can also be seen as a component of the post-COVID-19 syndrome.
4. COVID-19 results in a hypercoagulable state and thrombotic events can occur during the acute illness or convalescence. The most common haemostatic abnormalities in COVID-19 include mild thrombocytopaenia, increased D-dimer levels, prolongation of the prothrombin time (PT), international normalised ratio (INR), thrombin time (TT) and shortened activated partial thromboplastin time (aPTT).
5. Moderate or severe SARS-CoV-2 infection is frequently associated with acute kidney injury (AKI). The duration of COVID-induced kidney injury is not clear, and renal consequences of COVID-19 may be found even six months after discharge.
6. Hormonal and metabolic disturbances due to the involvement of the thyroid, pancreas and adrenal glands by the coronavirus have been reported. Direct viral damage to pancreatic islets due to coronavirus can lead to transient diabetes mellitus. Thyroid follicular damage, subacute thyroiditis leading to primary hypothyroidism, transient pituitary lesions and damage to hypothalamo-pituitary-adrenal axis leading to hypocortisolism and secondary hypothyroidism have been reported in patients recovering from SARS-CoV-2.
7. The most frequently reported long-term neurological sequelae of COVID-19 infection are anosmia, ageusia and cerebrovascular accidents.
8. Fatigue and muscle weakness are the most common post-COVID-19 symptoms. Significant physical deconditioning, critical illness myopathy, residual neuromuscular weakness and increased frailty may be seen in patients recovering from severe COVID-19 and must be considered while assessing the perioperative risk.
9. Psychiatric symptoms, including post-traumatic stress disorder, worsening of depression and anxiety, have been observed in COVID-19-recovered patients.
10. Gastrointestinal and liver dysfunction with symptoms such as loss of appetite, nausea, acid reflux, diarrhoea, abdominal distension, belching, abdominal pain and bloody stools can persist up to six months post-COVID-19. Abnormal aspartate aminotransferase and alanine aminotransferase levels, low albumin and elevated lactate dehydrogenase levels are often observed.
11. Cutaneous manifestations in COVID-19 patients may vary from urticarial, vesicular or maculopapular rash to various immune mediated inflammatory reactions.
12. The full scope of the long-term effects of COVID-19 and their clinical implications have not yet been fully understood. Similar to acute COVID-19, there is considerable variability in the presentation and severity of its sequelae. Knowledge of COVID-19-induced systemic effects is essential for an anaesthesiologist for better perioperative management of post-COVID-19 patients.
Perioperative management of post-COVID-19 patients scheduled for elective surgery
Timing of elective surgery
There are several factors which should be taken into account for deciding the optimal timing of elective surgery after recovery from COVID-19 including duration of COVID symptoms, the disease severity, the presence of post-COVID-19 multiorgan dysfunction and drugs used for COVID-19 management that can affect perioperative outcomes.
According to the advice of American Society of Anesthesiologists (ASA) and the Anaesthesia Patient Safety Foundation (APSF) COVID-19 patients should be made to wait for a few weeks after recovery for non-urgent or elective surgeries; four weeks for those who recovered from mild, non-respiratory symptoms; six weeks for symptomatic (including cough and shortness of breath) patients who did not require hospitalisation; 8–10 weeks for symptomatic patients who are diabetic, immunocompromised or hospitalised with COVID-19; and a minimum 12 weeks for patients who were admitted in an intensive care unit (ICU) with COVID-19.
According to Centres for Disease Control and Prevention (CDC), Reverse transcription-polymerase chain reaction (RT-PCR) re-testing is not recommended within 90 days of onset of COVID symptoms. In case a patient presents for surgery after 90 days of onset of COVID symptoms, a nasopharyngeal RT-PCR test is recommended ≤3 days prior to the date of scheduled surgical procedure.
The pre-anaesthetic evaluation in a post-COVID-19 patient should include proper history and physical examination, including functional assessment and mandated investigations, along with meticulous documentation. Estimation of effort tolerance, breath-holding time, an ambulatory oxygen saturation measurement.
Further a 6-min walk test (6MWT) should be performed in all patients. The tests for evaluation of cardio-pulmonary and nutritional status, renal and liver functions, coagulation system and inflammatory markers may be performed.
Tests for pre-operative evaluation in post-COVID-19 patients
During the pre-operative evaluation, the clinical assessment of COVID-19-recovered patients should be individualised, considering the severity of the disease, their post-COVID-19 functional status, associated co-morbidities, the surgical procedure and the benefit-risk ratio of postponement of surgery.
1.Arterial blood gas (ABG) analysis is not mandatory because arterial puncture is associated with the risk of haematoma, nerve/arterial injury.
2.Tests which should be done include Haemoglobin estimation ,White blood cell counts , LFTs in some select patients like elderly patients, ASA physical status class III and IV patients, those with a history of severe COVID-19, pre-existing liver conditions and documented significant liver dysfunction, renal function tests (RFTs),blood glucose testing (fasting and post-prandial) , Routine HbA1c in diabetic patients.
3.Clinical assessment, peripheral arterial oxygen saturation levels and chest X-ray provide useful information about the respiratory status of patients presenting for surgery.
4.The previous ECG of all patients with moderate to severe COVID-19 and treated in ICU should be evaluated.
5. One should look for Clinical features of primary/secondary hypothyroidism and hypocortisolism, such as fatigue, lassitude, weakness, malaise, orthostatic dizziness, anorexia, anxiety, depression and apathy, postural hypotension and low blood pressure.
6. Serum thyroid-stimulating hormone and free thyroxine (T4) levels can be estimated if hypothyroidism is suspected.
7. Further Serum cortisol estimation in the morning and adrenocorticotrophic hormone (ACTH) stimulation test can be advised in cases of suspected hypocortisolism and supplemental corticosteroids administered depending on the test results.
8. It is important tonote that supplemental perioperative corticosteroids are not indicated in those who have taken corticosteroids for less than three weeks/taken less than the equivalent of 5 mg of prednisolone daily/those undergoing superficial surgical procedures.
Other measures to be taken include cessation of smoking, chest physiotherapy, use of bronchodilators use, hydration correction, adjustment of the dose of corticosteroids and control of hyperglycemia, including adjustment of insulin doses, and treatment of ketoacidosis and improvement in nutrition.
Perioperative management of antithrombotic and anti-platelet agents
COVID-19-recovered patients may be on anti-platelet agents (such as low-dose aspirin),clopidogrel/ prasugrel/ ticagrelor/ ticlopidine, low molecular weight heparin (LMWH)/unfractionated heparin, Factor Xa inhibitors (such as fondaparinux) and direct oral anticoagulants (DOACs) such as betrixaban/ rivaroxaban/ apixaban/ dabigatran. Of these, the use of low-dose aspirin (75–150 mg/day) is safe and no special precautions are to be taken unless the patient presents for eye, prostate or neurosurgery.
For patients at high risk of cardiac events (except those with coronary stents), clopidogrel/prasugrel is discontinued 5 days preoperatively and is resumed 24 h post-operatively.
For patients at low risk of cardiac events, dual anti-platelet therapy is stopped 7–10 days preoperatively and resumed 24 h post-operatively.
For those with coronary stents, dual anti-platelet therapy, including aspirin and clopidogrel/prasugrel, is continued perioperatively if surgery cannot be postponed.
DOACs should ideally be discontinued 24–48 h prior to surgery depending on the risk of bleeding in the surgical procedure.
For those on once-daily prophylactic dose of LMWH, surgery should be undertaken at least 12 h after the last dose and restart 24 h after surgery.
The Studies regarding use of anti-fibrinolytics, such as tranexamic acid, aprotinin and epsilon aminocaproic acid
in the post-COVID-19 scenario are currently lacking.Therefore if an increase in bleeding is observed, the most reasonable solution would be to administer fresh frozen plasma (FFP).
1. The patient should be reassured and premedicated depending on the lung status with a short-acting benzodiazepine such as midazolam.
2. Regional anaesthesia (RA) is an important option as far as possible.
3. When administering general anaesthesia (GA), optimal oxygenation by providing adequate inspired oxygen concentration should be ensured.
4. Heat and moisture exchange filters should be used to maintain mucociliary function.
5 Preferably Propofol or etomidate may be used as induction agents and Vecuronium, cis-atracurium and atracurium can be used as agents for neuromuscular blockade.
Suxamethonium or rocuronium can be used for rapid sequence tracheal intubation. The anaesthesia is maintained preferably with an air-oxygen mixture and inhalational agents such as sevoflurane/isoflurane/desflurane along with intra-operative analgesics, fentanyl. Adequate reversal of the neuromuscular block is important.
In patients with renal dysfunction, due care may be exercised while using drugs that are normally excreted by the kidney, such as meperidine, NSAIDS, ACE inhibitors and and renally excreted antibiotics and muscle relaxants.
Post-operative care including analgesia
The patients should be shifted to the ICU/ward followed by oxygen supplementation and ventilatory support depending on the post-operative condition, presence of co-morbidities and degree of invasiveness of surgery.
The haemodynamics and adequate analgesia especially for those with cardiovascular problems should be Judiciously monitored to prevent any untoward cardiovascular events.
Multi-modal analgesia can be provided using epidural analgesia, nerve blocks, neuromodulators, opioids, tramadol, paracetamol and NSAIDs.
Perioperative management of emergency surgery in post-COVID-19 patients
Trauma, emergency caesarean sections and exploratory laparotomies are the most likely emergency scenarios which will be encountered.
Multimodal analgesia should be employed in all cases. Epidural analgesia should be planned in laparotomies and employed where feasible to optimise post-operative analgesia and ease breathing. Extubation needs careful assessment and planning. Nitrous oxide should be switched off early to allow complete washout. Sevoflurane may be preferred for maintenance of anaesthesia considering its effective bronchodilation effect and rapid removal.
Complete reversal of neuromuscular blockade should be ensured. Opioid top-ups should be timed to avoid undue sedation at the time of extubation. Awake extubation should be performed provided the patient does not have any significant cardiac ailment. Post-extubation continuous positive airway pressure or high-flow nasal oxygen can be administered where necessary. Patients should be monitored closely for respiratory failure or deterioration. Post-operative thromboprophylaxis can be considered for all patients.
For emergency caesarean section in COVID-19 recovered women,RA is the preferred technique, wherever feasible. GA should be preferred in patients with decreased cardio-pulmonary reserve. Rapid sequence induction is employed. A higher FiO2 may be maintained till foetal delivery to ensure adequate foetal oxygenation considering the poor maternal pulmonary reserve. Good post-operative analgesia should be provided. A transversus abdominis plane block may be employed. Mechanical and pharmacological thromboprophylaxis should be considered post-operatively while targeting early ambulation.
RA in patients on anticoagulation
In emergency the patients should not receive RA, if patients are on anticoagulants as incidence of spinal haematoma is increased in these cases when RA is attempted. The specific medication and the timing of the last dose of antithrombotic medications are vital for planning neuraxial/deep perineural procedures.The recommended minimum time interval between antithrombotic agent administration and neuraxial puncture/catheter removal (before puncture/removal and after puncture/catheter manipulation/removal) is as follows: 1) Prophylactic/therapeutic unfractionated heparin: 4–6 h, 1 h; 2) Prophylactic LMWH: 12 h, 4 h; 3) Therapeutic LMWH: 24 h, 4 h; 4) Fondaparinux: 36–42 h, 6–12 h; 5) Rivoroxaban/Apixaban: 22–30 h, 6 h. 6) Dabigatran: 5 d, 6 h (The experience with dabigatran and neuraxial anaesthesia is limited). The recommended time interval between discontinuation of anti-platelet agents and neuraxial puncture is as follows: Clopidogrel/ticagrelor: 5–7 d; prasugrel: 7–10 d; ticlopidine: 10 d; cangrelor: 3 h. They can be resumed 6 h after puncture/catheter removal. All these drugs are contraindicated with the catheter in place.
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Indian J Anaesth. 2021 Jul; 65(7): 499–507.Published online 2021 Jul 23.