|Year : 2020 | Volume
| Issue : 2 | Page : 65-68
Safe anesthesia and analgesia for obstetric patients in COVID 19 pandemic
Samina Ismail, Asiyah Aman
Department of Anaesthesiology, Aga Khan University Hospital, Karachi, Pakistan
|Date of Submission||23-Jun-2020|
|Date of Acceptance||03-Jul-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Samina Ismail
Department of Anaesthesiology, Aga Khan University Hospital, Stadium Road P.O. Box 3500, Karachi 74800
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ismail S, Aman A. Safe anesthesia and analgesia for obstetric patients in COVID 19 pandemic. J Obstet Anaesth Crit Care 2020;10:65-8
|How to cite this URL:|
Ismail S, Aman A. Safe anesthesia and analgesia for obstetric patients in COVID 19 pandemic. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2021 Jan 19];10:65-8. Available from: https://www.joacc.com/text.asp?2020/10/2/65/292745
The new severe acute respiratory syndrome coronavirus (SARS-CoV-2) disease (COVID -19) has emerged as a global crisis and is placing an immense burden on health care. Pregnant women are supposed to have relatively depressed immunity and on a theoretical basis can have a higher chance of contracting an infection. However, current evidence suggests that pregnant women are no more at risk of COVID-19 than other adults nor is the condition thought to be more severe in them., However, there is scarce information on the assessment and management of parturient infected with COVID-19, and the vertical transmission to the fetus is still unclear. With a rapid spread of this pandemic, prevention is better than cure. Therefore, in the absence of bedside testing for COVID-19, all parturients who require anesthesia services should be assumed to be carriers of Sars-CoV-2.
This editorial aims to discuss the clinical features of a pregnant patient with COVID 19, safety preparation and different anesthetic regimens of patients with COVID19 undergoing cesarean section (CS), safety and efficacy of different analgesic options for labor, and different available guidelines for obstetric anesthesia care and regional anesthesia related to COVID 19.
Clinical Features of Pregnant Patients with COVID- 19
The signs and symptoms of COVID-19 infection in a large data set of nonpregnant patients from China were fever, fatigue, cough, shortness of breath, myalgia, headache, sore throat, diarrhea, nausea, and vomiting. An additional manifestation noted among patients with COVID-19 infection is the sudden loss (or reduction) of the sense of smell and taste, which is currently recommended by the American Academy of Otolaryngology- Head and Neck Surgery as a part of screening for COVID-19 infection.
The most common changes in the laboratory test was an increased change in plasma C-reactive protein in 52.8% of patients, followed by a decreased lymphocyte count in 33.7% and leukocytosis in 23.6% of the patients. In addition, some cases had mild liver and kidney dysfunction. In one retrospective study, all patients tested positive for COVID-19, present with ground-glass opacities on chest computed tomography scan.
In pregnancy, the presentation of COVID-19 infection appears similar, but many of these nonspecific symptoms may be attributed to symptoms of pregnancy and labor. For example, signs of latent labor may include myalgia and diarrhea; pre-eclampsia can present with headache; shortness of breath is perceived during pregnancy and labor; and chorioamnionitis may cause tachycardia and fever, leading clinicians to overlook COVID-19 infection as a possible diagnosis.
In addition, women infected with COVID-19 may be asymptomatic until their admission in labor and beyond, which poses a significant risk of exposure for their family members (including the newborn) and all providers involved in their clinical care.
| Safety Preparation for Cs|| |
Safety preparation for CS includes operating room preparation, personnel entry and exit procedure, and medical staff protection. Personnel protection equipment (PPE) should be used in different workspaces. Biosafety level-3 (BSL-3) protective medical equipment should be worn during any procedure on COVID-19 pregnant patients, which includes wearing N95 masks, goggles, protective suits, disposable medical caps, and medical rubber gloves. If anesthesiologists are involved in giving general anesthesia with endotracheal intubation, a powered air-purifying respirator should be used.
Patients should be transferred between the isolation ward and operating room by a negative pressure isolation transfer cabin by staff wearing BSL-3 protective medical equipment. The patients should wear regular surgical masks throughout the process to reduce viral spread. The negative pressure operating rooms need to be used for CS for a parturient with COVID-19, and the medical personnel entry and exit in the operating room should be in strict accordance with the principles of clean area, contaminated pollution area, and buffer zones. Designated nurses should be ensuring the implementation of standard procedures. After surgery, the anesthesia workstation should be disinfected for 2 h with an anesthesia circuit sterilizer (containing 12% hydrogen peroxide). Chlorine containing disinfectant should be used to clean the operating room floor and surfaces of reusable medical equipment, including anesthesia workstation and monitors.
| Safety and Efficacy of Different Anesthesia Techniques for Covid-19 Patients Undergoing Cs|| |
COVID-19 can cause quick deterioration of lung function; therefore, the ideal timing of CS is important to ensure the safety of the mother and fetus. Both neuraxial and general anesthesia have been used safely for patents undergoing CS. However, as the lung is the most vulnerable organ for COVID 19, the choice of anesthetic technique for CS is critical for pregnant women with COVID-19.
The benefits of neuraxial analgesia in the setting of COVID-19 pneumonia are two-fold: (1) for patients, it will help avoid any exacerbation of respiratory status with intubation and mechanical ventilation and (2) for health care providers, it reduces the risks associated with aerosol exposure and transmission of COVID-19 infection during intubation and extubation associated with general anesthesia.
In terms of the risk of meningitis or encephalitis associated with neuraxial procedures, one review on neuraxial procedures on COVID-19 positive patients states a low risk of meningitis or encephalitis with neuraxial procedures.
As preliminary reports have suggested thrombocytopenia in severe COVID-19 patients, it is advisable to have a platelet count before regional anesthesia. It is, generally, safe to perform neuraxial procedures at platelet counts of 70,000 × 106/L or above as the risk of spinal/epidural hematoma is rare. Therefore, considering the higher risk of respiratory compromise with general anesthesia, neuraxial procedures at even lower platelet counts should be considered. There is a debate on excessive hypotension with regional anesthesia,, with the probable reason for the binding of SARS-CoV-2 with the angiotensin-converting enzyme II (ACE2) receptor. The key of SARS-CoV-2 infection is its S-protein binding with the ACE2 receptor. These studies imply that the circulatory system is highly susceptible to SARS-CoV-2 infection.
Emergency CS (decision-to-delivery within 30 min) mandates a systematic plan and preparedness for minimizing cross contaminations. When a COVID-19 parturient with desaturation (SO2≤93%) presents for emergency CS, general anesthesia needs to be administered. This must be done with rapid sequence induction and tracheal intubation with a cuffed tube with full precaution. Extubation after general anesthesia should be performed with the same precautions as during the conduct of intubations, as patients tend to be more agitated during emergence from anesthesia. This could result in higher chances of viral dissemination from coughing as compared with the intubation process.
When the parturient oxygen saturation is adequate (≥94%), regional anesthesia with an epidural top-up or single-shot subarachnoid blockade needs to be actively considered in place of general anesthesia to minimize aerosolization and cross-infection during airway management. Where there is a working epidural catheter in place for ongoing labor analgesia, administering a top-up with potent local anesthetics (e.g., 10 ml to 15 ml of 1.5% lignocaine, alkalinized with 8.4% sodium bicarbonate) achieve anesthesia plane for surgery with a rapid onset of 3.5 min.
| Safety and Efficacy of Different Analgesia Options for Labor|| |
COVID-19 patients requiring labor analgesia needs to be admitted in the isolation room preferably a negative pressure labor room with limited number of health care providers. All health care workers should implement airborne and contact precautions with eye protection upon entering a delivery or operating room (gown, gloves, mask, and eye protection). Suspending nitrous oxide programs in labor and delivery units because of concerns of aerosolization in even asymptomatic patients, as there is insufficient information regarding safety in this setting, should be considered. In addition, the practice of high flow oxygen for fetal distress does not improve fetal outcomes and should be suspended because of the risk of aerosolization.
Early epidural analgesia may reduce the need for general anesthesia for emergent cesarean delivery. Assign the most experienced anesthesia provider whenever possible for procedures like labor neuraxial analgesia techniques.
| Different Guidelines for Obstetric Anesthesia Care Related to Covid-19|| |
Society for Obstetric Anesthesia and Perinatology has formulated interim guidance for obstetric anesthesia care related to COVID-19 patients based on expert opinion and published recommendations from World Health Organization and Centers for Disease Control and Prevention on March 15, 2012.
The Obstetric Anaesthetists' Association, the Faculty of Intensive Care Medicine, the Intensive Care Society, the Association of Anaesthetists, and the Royal College of Anaesthetists have released a set of generic recommendations on the management of pregnant patients with suspected or confirmed COVID-19.
A joint statement by the American Society of Regional Anesthesia and Pain Medicine and European Society of Regional Anaesthesia & Pain Therapy has formulated practice recommendations for neuraxial anesthesia and peripheral nerve block during the COVID-19 pandemic.
Health care facilities caring for COVID-19 parturients need to establish good communication channels among health officials, institutional leadership, and ground staff. Protocols and pathways in line with international guidelines should be formulated with timely dissemination of updated information and a mechanism for obtaining feedback. A review article in this issue describes in detail the various implications of the disease, drugs, and management issues.
| Conclusion|| |
To provide sustainable and safe obstetric anesthesia during an infectious disease pandemic, a collaborative effort among anesthesiologists, intensivists, obstetricians, neonatologists, nursing, infectious disease physicians, and environmental services is required to minimize infection risks to both patients and health care workers. Constant review of the criteria of the high infection-risk patient, aligned to the evolving global situation, facilitates effective screening, isolation, and management. Protocols and workflows are required in every health care facility according to the recommendation from the international societies for the management of such patients in labor and operative deliveries. These protocols will need frequent revision to enhance efficiency while optimizing the use of finite resources. Lastly, establishing good communication channels among health officials, institutional leadership, and ground staff is pivotal for the timely dissemination of updated information and obtaining feedback.
The authors would like to thank Ms. Seharish Sher Ali from the Department of Anesthesia, Aga Khan University for her significant contributions to the formatting of the manuscript.
Financial support and sponsorship
No funding source to disclose for this study.
Conflict of interest
All the authors of this study have no interest in terms of financial or other relationships that might lead to a conflict of interest.
| References|| |
Qiao J. What are the risks of COVID-19 infection in pregnant women? Lancet 2020;395:760-2.
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al
. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. Lancet 2020;395:809-15.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al
. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
Kaye R, Chang CWD, Kazahaya K, Brereton J, Denneny JC, Denneny JC 3rd
. COVID-19 Anosmia Reporting Tool: Initial findings. Otolaryngol Head Neck Surg 2020;163:132-4.
Zhang Y, Chen R, Wang J, Gong Y, Zhou Q, Cheng HH, et al
. Anaesthetic management and clinical outcomes of parturients with COVID-19: A multicenter, retrospective, propensity score matched cohort study. medRxiv 2020;1:1-17. doi: 10.1101/2020.03.24.20042176.
Bauer M, Bernstein K, Dinges E, Delgado C, El-Sharawi N, Sultan P, et al
. Obstetric anesthesia during the COVID-19 pandemic. Anesth Analg 2020;131:7-15.
Benhamou D, Meyer HK, Morau E, Chassard D, Mercier FJ; French Obstetric Anesthesia Working Group (Club Anesthésie-Réanimation en Obstétrique [CARO]). Spinal anesthesia for Cesarean delivery in women with COVID-19 infection: questions regarding the cause of hypotension. Can J Anaesth. 2020;67(8):1097-1098. doi:10.1007/s12630-020-01663-y.
Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anesth 2020;67:568-76.
Birnbach DJ, Bateman BT. Obstetric anesthesia: Leading the way in patient safety. Obst Gyne Clin 2019;46:329-37.
Bauer ME, Chiware R, Pancaro C. Neuraxial procedures in COVID-19 positive parturients: A review of current reports. Anesth Analg 2020;131:22-4.
Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta 2020;8981:145-8.
Van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol 2010;148:15-25.
Zhou D, Cai W, Zhang W. An adaptive wavelet method for nonlinear circuit simulation. IEEE Trans Circuits Syst I Fundam Theory Appl 1999;46:931-8.
Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al
. Genomic characterisation and epidemiology of 2019 novel coronavirus: Implications for virus origins and receptor binding. Lancet 2020;395:565-74.
Ashokka B, Loh M-H, Tan CH, SU LL, Young BE, Lye DC, et al
. Care of the pregnant woman with COVID-19 in labor and delivery: Anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel. Am J Obst 2020;223:66-74.e3.
Miller E, Leffert L, Landau R. Society for Obsteric Anestesia and Perinatology. Interim Con-siderations for Obstetric Anaesthesia Care related to COVID19 (drafted 3/15/2020, most recent update: 4/5/2020). Available from: http://soap.org
. [Last accessed on 2020 Mar 12].
Lee JSE, Goy RWL, Sng BL, Lew E. Considerations and strategies in the organisation of obstetric anaesthesia care during the 2019 COVID-19 outbreak in Singapore. Int J Obstet Anesth 2020;43:114-17.
Ganesh V, Bhatia R, Trikha A. COVID-19: Considerations for Obstetric Anesthesia and Analgesia. J Obstet Anaesth Crit Care 2020;10:69-74. [Full text]