Neuraxial anaesthesia and peripheral nerve blocks during the COVID‐19 pandemic: a literature review and practice recommendations

Abstract

Summary Coronavirus disease 2019 (COVID‐19) has had a significant impact on global healthcare services. In an attempt to limit the spread of infection and to preserve healthcare resources, one commonly used strategy has been to postpone elective surgery, whilst maintaining the provision of anaesthetic care for urgent and emergency surgery. General anaesthesia with airway intervention leads to aerosol generation, which increases the risk of COVID‐19 contamination in operating rooms and significantly exposes the healthcare teams to COVID‐19 infection during both tracheal intubation and extubation. Therefore, the provision of regional anaesthesia may be key during this pandemic, as it may reduce the need for general anaesthesia and the associated risk from aerosol‐generating procedures. However, guidelines on the safe performance of regional anaesthesia in light of the COVID‐19 pandemic are limited. The goal of this review is to provide up‐to‐date, evidence‐based recommendations or expert opinion when evidence is limited, for performing regional anaesthesia procedures in patients with suspected or confirmed COVID‐19 infection. These recommendations focus on seven specific domains including: planning of resources and staffing; modifying the clinical environment; preparing equipment, supplies and drugs; selecting appropriate personal protective equipment; providing adequate oxygen therapy; assessing for and safely performing regional anaesthesia procedures; and monitoring during the conduct of anaesthesia and post‐anaesthetic care. Implicit in these recommendations is preserving patient safety whilst protecting healthcare providers from possible exposure.

Pregnancy and COVID‐19: pharmacologic considerations

“…Pre-procedure ultrasound-assistance can be considered to facilitate epidural insertion 36 , while following current guidelines for cleaning and preparing equipment 37 . An early epidural placement may reduce the need for general anaesthesia in case of conversion to caesarean delivery 3,36 . Although no pharmacological changes in regular dosing have been recommended, a modified epidural infusion regimen (local anesthetic concentration, adjuvants and/or pump settings) may be considered in order to minimize in-person contact with patients with COVID-19 36 patients with respiratory symptoms such as the increased risk of respiratory depression, as well as the increased risk of vomiting, which could potentially generate aerosols 41 .…”

Cirugía de cadera ante la pandemia COVID-19

“…17,18 Anestesia. La anestesia neuroaxial y los bloqueos nerviosos periféricos son la primera opción (siempre que sea posible) para el manejo anestésico de pacientes con sospecha de infección por COVID-19, la cual debe realizarse en quirófano con EPP (guantes, bata, mascarilla quirúrgica y gafas) 19 con la menor cantidad posible de personal dentro de sala de quirófano. En caso de no ser posible y necesitar anestesia general se debe tener, igualmente, la cantidad mínima de personal que cuente con equipo completo de EPP, caja de vías respiratorias para protección, caja con medicamentos preparados y un video laringoscopio; la intubación endotraqueal será realizada por el anestesiólogo con más experiencia.…”

Patient under Investigation for COVID-19 Undergoing Appendectomy at Songklanagarind Hospital

“…We selected spinal anesthesia rather than general anesthesia with orotracheal intubation to lessen the risk of viral transmission. 10,11 Recommendations based on the current literature regarding safe administration of neuraxial anesthesia for a suspected COVID-19 patient are as follows. 11,12 First, all patients should wear a surgical facemask to restrict droplet spread.…”

“…10,11 Recommendations based on the current literature regarding safe administration of neuraxial anesthesia for a suspected COVID-19 patient are as follows. 11,12 First, all patients should wear a surgical facemask to restrict droplet spread. Second, use of supplemental oxygen should be minimized to maintain oxygen saturation.…”

“…7 For this case, even though spinal anesthesia was performed to minimize viral transmission, an anesthesia back-up team should be standing by in case of an emergency or if anesthesia supplies are required. 11…”