What are the risks of general anesthesia in patients with COVID-19 (Coronavirus Disease 2019)?

Risks of General Anesthesia with COVID-19

General anesthesia in COVID-19 patients significantly increases infection transmission risk to healthcare workers and poses greater respiratory complications for patients, making regional anesthesia the preferred option whenever possible. 1

Primary Risks

For Healthcare Workers

• Aerosol Generation: General anesthesia procedures (intubation and extubation) are high-risk aerosol-generating procedures that significantly increase viral transmission 1
• Transmission Risk: Healthcare workers performing tracheal intubation have 6.6 times higher odds of contracting respiratory infections compared to those not exposed to this procedure 1
• Staff Exposure: Operating room personnel are at elevated risk during airway management of COVID-19 patients 1

For Patients

• Respiratory Complications: COVID-19 patients have compromised lung function, increasing the risk of:
  • Postoperative respiratory failure
  • Prolonged mechanical ventilation
  • Difficult weaning from ventilator support 2
• Thrombotic Events: COVID-19 increases risk of perioperative thrombotic complications 1
• Hemostasis Disorders: Severe COVID-19 can cause thrombocytopenia and other coagulation abnormalities 1

Risk Mitigation Strategies

Anesthesia Selection

• Prioritize Regional Anesthesia: Neuraxial anesthesia and peripheral nerve blocks should be first-choice whenever feasible 1
• Benefits of Regional Techniques:
  • Avoid aerosol generation
  • Reduce postoperative pulmonary complications
  • Conserve critical anesthetic drugs 1

When General Anesthesia is Necessary

1. Airway Management:

   • Use rapid sequence induction to minimize aerosolization 2
   • Employ video laryngoscopy for first-attempt success 2
   • Ensure adequate muscle relaxation to prevent coughing 2
   • Use cuffed endotracheal tubes with appropriate pressure (25-30 cmH2O) 2

2. Ventilation Strategy:

   • Implement lung-protective ventilation (6-8 ml/kg ideal body weight) 2
   • Apply optimal PEEP to prevent alveolar collapse 2
   • Maintain higher oxygen saturation targets (94-95%) 2
   • Use closed suction systems for tracheal suctioning 1

3. Extubation Considerations:

   • Perform extubation in the operating room rather than recovery area 2
   • Consider deep extubation when appropriate to reduce coughing 2
   • Apply surgical mask to patient immediately after extubation 2

Infection Control Measures

1. Personal Protective Equipment:

   • N95/FFP2 respirators, face shields/goggles, head caps, fluid-resistant gowns, and gloves for all airway procedures 1, 2
   • Minimize staff present during intubation/extubation 1, 2

2. Operating Room Management:

   • Use dedicated COVID-19 operating rooms with clear signage 1, 2
   • Minimize traffic in and out of the operating room 1
   • Allow adequate time between cases for air exchange 1
   • Prefer disposable equipment when possible 1

Special Considerations

Preoperative Assessment

• Comprehensive pulmonary function assessment including arterial blood gas analysis 2
• Evaluation of oxygen requirements at rest and with exertion 2
• Assessment of previous COVID-19 severity, hospitalization history, and ventilatory support 2

Drug Interactions

• Be aware of potential interactions between COVID-19 treatments and anesthetic drugs 1
• Adjust dosages of anesthetic medications as needed, particularly with antivirals like lopinavir/ritonavir which can affect metabolism of many anesthetic agents 1

Common Pitfalls to Avoid

1. Underestimating Transmission Risk:

   • Never perform aerosol-generating procedures without appropriate PPE, even in asymptomatic patients 1

2. Inadequate Preparation:

   • Failure to have emergency reintubation equipment readily available 2
   • Not planning for potential deterioration in respiratory status 2

3. Improper Extubation Technique:

   • Extubating without minimizing coughing and aerosol generation 2
   • Performing extubation in recovery areas rather than operating rooms 2

4. Overlooking Thrombotic Risk:

   • Not implementing appropriate thromboprophylaxis in COVID-19 patients 1

By carefully considering these risks and implementing appropriate mitigation strategies, the safety of both patients with COVID-19 and healthcare workers can be optimized during necessary surgical procedures requiring anesthesia.