International hospitals and healthcare facilities face catastrophic financial challenges related to the COVID-19 pandemic. The American Hospital Association estimates a financial impact of $202.6 billion in lost revenue for America's hospitals and health systems, or an average of $50.7 billion per month. Furthermore, it could cost low- and middle-income countries ∼ US$52 billion (equivalent to US$8.60 per person) each four weeks to provide an effective health-care response to COVID-19. In the setting of the largest daily COVID-19 new cases in the US, this burden will influence patient care, surgeries, and surgical outcomes. From a global economic standpoint, The World Bank projects that global growth is projected to shrink by almost 8% with poorer countries feeling most of the impact, and the United Nations projects that it will cost the global economy around 2 trillion dollars this year. Overall, a lack of preparedness was a major contributor to the struggles experienced by healthcare facilities around the world. Items such as personal protective equipment (PPE) for healthcare workers, hospital equipment, sanitizing supplies, toilet paper, and water were in short supply. These deficiencies were exposed by COVID-19 and have prompted healthcare organizations around the world to invent new essential plans for pandemic preparedness. In this paper we will discuss the economic impact of COVID on US and international hospitals, healthcare facilities, surgery, and surgical outcomes. In the future the US and countries around the world will benefit from preparing a plan of action to use as a guide in the event of a disaster or pandemic.

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The COVID-19 (also named as 2019-nCoV) is a very contagious novel coronavirus. Though most patients contracted the 2019-nCoV will likely have mild symptoms with good prognosis, some will develop severe acute respiratory infection, pneumonia, or acute respiratory distress syndrome. Some of these patients will need anesthesia care for endotracheal intubation, critical care management and surgical services. Perioperative care services will face enormous challenges in managing these patients with the COVID-19. The challenges are how to protect perioperative care providers and how to avoid cross-infection by transmitting the COVID-19 to other individuals, in addition to managing their respiratory failure and other pathophysiological disturbances. In this article, we discussed the personal protective equipment and techniques of using them, and strategies to prevent or minimize the probability of cross-infection of the COVID-19 from infected patient to other individuals. Perioperative care provider's self-protection includes universal precautions, wearing gloves, facemask, eye protections, and coverall gowns. Preventive measures of cross-infection include isolation room in paranesthesia holding area or straight to the operating room bypassing paranesthesia holding area, ventilation circuit filter(s), and circuit, CO 2 absorbent and cannister replacement after each use, airborne and droplet precautions, and establishment of department and hospital-wide crisis management protocols. Perioperative care providers may encounter numerous unexpected difficulties such as poor visibility inside the coverall gowns, difficult to communicate verbally due to voice baffling, providers may become hyperthermia and sweating inside the gowns. The COVID-19 is a new disease, its transmission, clinical presentation, diagnosis and management are evolving, our perioperative care will need modification accordingly.

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BackgroundTremendous changes have occurred in enhanced recovery after surgery (ERAS) since Danish surgeon Dr Kehlet published his landmark article in 1997, emphasizing that major surgical procedures may lead to significant undesirable sequelae, including infection, pain, hemorrhage, cardiopulmonary and thromboembolic complications, ileus, postoperative nausea and vomiting, fatigue, and prolonged convalescence. 1 In this regard, the surgical stress response and its subsequently increased demands on organ function is the critical factor influencing postoperative

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Management of neuraxial anesthesia/analgesia in anticoagulated patient can be challenging. The shortest safe time to remove epidural catheter, after a patient receives long-acting dual antiplatelet agents (clopidogrel and aspirin), is unclear. American Society of Regional Anesthesiology (ASRA) guidelines recommend seven days interval for the epidural placement after clopidogrel administration. However ASRA Guideline did not specify the time for epidural catheter removal, and did not specify how much time elapse necessary after dual antiplatelet therapy with clopidogrel and aspirin. We report a case of safe removal of epidural catheter 72 hours after oral dose of clopidogrel and aspirin with a normal platelet function analysis and normal thromboelastography before removal.