Cardiac anesthesia and COVID-19 outbreak: What should we know?
Mohsen Ziyaeifard1, Parisa Ziyaeifard2
1 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
|Date of Submission||02-Apr-2020|
|Date of Decision||26-Apr-2020|
|Date of Acceptance||19-May-2020|
|Date of Web Publication||30-Sep-2020|
Dr. Parisa Ziyaeifard
Faculty of Medicine, Iran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
The COVID-19 outbreak is public health emergency, spreads easily from human to human, and may cause acute severe respiratory syndrome. The anesthesia teams who perform this procedure are at risk aerosolization and need special consideration and safety measures. Cardiac anesthesiologist follows two aims, recognition of COVID-19 patients that need surgery and decreasing the risk of perioperative viral transmission to coworkers. An isolated operating room (negative pressure operating room for COVID-19) should be available. It is important to regulate workflow and practices, anesthesia management, healthcare, and staff. Cardiac anesthesiologist and health-care workers must be use guidelines to treat patients with COVID-19.
Keywords: Anesthesia, cardiac surgical procedures, COVID-19, novel coronavirus
|How to cite this article:|
Ziyaeifard M, Ziyaeifard P. Cardiac anesthesia and COVID-19 outbreak: What should we know?. J Res Med Sci 2020;25:89
| Introduction|| |
The World Health Organization announced COVID-19 outbreak as a public health emergency around the world on the last of January 2020 health care in situ ation to outbreaks of rising COVID-19, and hospital population are at notably enlarged risk for difficulty from disease. Transmission within health-care services to health staff was known 3.8% of COVID-19 cases. Potential forms of transmission include respiratory droplets, contact, infected surfaces, and the fecal–oral path. Now, there is no definite evidence of airborne transmission of COVID-19. When the patient is symptomatic, it is most likely to spread infection but can be transmitted by asymptomatic patient.
According to the study of Chen et al., the most common sign and symptoms of this disease are fever, cough, and shortness of breath. Less common sign and symptoms of this disease are muscle pain, confusion, headache, sorethroat, rhinorrhea, and chest pain. Independent predictors of outcome in COVID-19 include age and concomitant conditions (diabetes, heart diseases, obesity, hypertension, chronic kidney disease, and chronic obstructive pulmonary disease). The patients with coronary heart disease and heart failure are at high risk for exposure to the virus. COVID19 virus can possibility destabilize coronary plaque throughout numerous mechanisms such as systemic inflammatory responses and increased risk of acute events.
The role of the anesthesiologist at the time of the outbreak is to coordinate the treatment team in the operating room. COVID-19 can survive for at least 3 days on materials of operating room (steel device and plastic). Operating room needs cleaning performance more than usual, particularly for noncritical items such as near bedside equipment. This implementation decreases the risk of cross contamination during patient care  Cardiac anesthesiologist follows two aims, recognition of COVID-19 patients that need surgery and decrease the risk of perioperative viral transmission to coworkers. An isolated operating room (negative pressure operating room for COVID-19) should be available. It is important to regulate workflow and practices, anesthesia management, health care, and staff. Cardiac anesthesiologist and health-care workers must be use guidelines to treat patients with COVID 19.
Therefore, in this article, we discuss about the strategic management with respect to cardiac operating room, the safety of cardiac surgery patients and cardiac anesthesiologist and health workers for prevention of the COVID-19, and what the cardiac anesthesiologist should do for the prevention of COVID-19.
| General Conditions in Operating Room of Cardiac Surgery for Prevention of the COVID-19|| |
The evidence-based improvement shows combination deep cleaning and using ultraviolet (C) reduced environmental contamination. Enhanced handwashing, patient decolonization, environmental cleaning, vascular access care, and supervision optimization should be improved for better perioperative infection control for both viral and bacterial pathogens. Anesthesiologists including cardiac anesthesiologist and health-care providers can start with steps 1–4 that include hand hygiene, environmental cleaning, patient decolonization, and vascular care, then progress to a vigorous plan of constant carefulness and surveillance.
| Strategic Management in Operating Room of Cardiac Surgery for Prevention of the COVID-19|| |
The strategic management are as following:
- In the situation of this pandemic, cardiac surgical procedures are restricted to urgent and emergent procedures ,
- A single negative pressure operating room should be with separate access for COVID-19 patients requiring surgery 
- Personal protective equipment should be available in operating room for COVID-19
- Anesthetic drugs should be used by precaution due to cardiac side effects of COVID-19 medications (antiviral drugs)
- Cardiac anesthesiologists and health-care providers play an essential role to prepare airway management in the operating room. Therefore, the safety of the anesthesia providers and the patients who implicated in this procedure need special consideration and safety measures 
- Standard monitoring (electrocardiogram, blood pressure, pulse oximetry, and end-tidal CO2), invasive blood pressure, central venous pressure, and advanced hemodynamic monitoring transesophageal echocardiography, bispectral index, cerebral oximetry,…) if needed, should be used in cardiac surgery patients who have COVID-19
- A close airway suction system for using should be prepared
- Difficult airway management equipment should be available
- Inotrope and vasopressor drugs including epinephrine, nor epinephrine, phenylepherine, and milrinone should be available. Emergency trolley should be immediately ready
- Mechanical hemodynamic support such as intra-aortic balloon pump and extracorporeal membrane oxygenation (ECMO) should be available. ECMO should be used in severe respiratory and/or cardiac failure
- If it is possible, the number of health-care members involve in the management should be reserved minimally with no or minimal exchange of staff in the duration of the procedure.
| The Safety of the Cardiac Surgery Patient|| |
COVID-19 patients potentially implicate in myocardial injury and multi-organ failure that cause hemodynamic instability condition and decrease arterial oxygen saturation. While critically ill patient's oxygen reserve is very poor, this makes a huge challenge for anesthesia team. In these patients, for anesthesia induction, anesthetic drugs should be selected on clinical judgment and rapid sequence induction is recommended. For the prevention of contamination in the operating room, it is better not to use anesthetic inhalation. Cardiac anesthesiologists should use total intravenous anesthesia (TIVA) for induction and maintenance of anesthesia.,
To avoid virus spreading, mask ventilation should not be used. If mask ventilation is required, it is recommended to put wet gauze around patient's nose and mouth. In this situation to prevent severe hypoxemia and circulatory failure, preoxygenation with 100% oxygen and muscle relaxant needs to be used. A high-efficiency particulate air filter should be used to the patient ending of the breathing circuit and between the expiratory branch and the anesthetic machine before anesthesia induction. Also for maximal patient safety, experienced anesthesia team (two anesthesiologists and one nurse) should perform tracheal intubation.,
Cardiac anesthesiologists should be also aware that the COVID-19 clinical manifestations (fever, cough, dyspnea, and exhaustion) can be mistaken with signs and symptoms of complication of cardiac surgery including pleural effusion, pericardial effusion, endocarditis, and mediastinitis.
| Anesthesia Induction and Connecting Patient to the Anesthesia Machine|| |
Cardiac anesthesiologists should use TIVA for the induction of anesthesia. After muscle relaxant, the drug is administrated (<15–20 s), and tracheal intubation by video laryngoscope with a disposable cover may be chosen over direct visualization to decrease the risk of droplet transmission. Fogging of goggles is a serious challenge for the tracheal intubation and for the care providers because of poor visibility; therefore, using antifogging agent of the inner site of goggles is recommended, then inflating endotracheal tube cuff. When tracheal intubation is difficult, a laryngeal mask should be used temporarily, and a multidisciplinary difficult airway team and bedside tracheostomy should be available.,
Cardiac anesthesiologists prove the location of the tracheal tube by auscultation and observation of bilateral chest expansion and end-tidal CO2 measurement. By inserting a filter on the respiratory tract, the patient is connected to the anesthesia machine.,,
| the Safety of the Cardiac Anesthesiologists and Health-Care Provider|| |
Cardiac anesthesiologists and health-care workers play a vital role to set up airway management in an operating room. As the anesthesia team and the health-care providers who perform this procedure are at risk of aerosolization, there is a need for special consideration and safety measures. According to the study of Luo et al., a high level of protection is necessary for the prevention of infection. Standard three levels are considered as following:
(1) Hand washing → head cover → mask N95 → surgical mask → isolated gown → disposable latex gloves → (2) goggles → protective clothing → disposable latex gloves → shoe covers → (3) disposable gown → disposable latex gloves → full head cover [Figure 1].
|Figure 1: Protection of health-care providers in the emergency operating room for the prevention of COVID-19|
Click here to view
The intubation team should be dressed in gowns, double mask with N95, and double gloves.
The person who is doing intubation should wear a third pair of gloves and remove them instantly after tracheal intubation.,
| Conclusion|| |
The COVID-19 outbreak is a public health emergency, spreads easily from human to human, and may cause acute severe respiratory syndrome. The safeties of the anesthesia team who perform this procedure are at risk aerosolization and need special consideration and safety measures. Cardiac anesthesiologist follows two aims, recognition of COVID-19 patients that need surgery and decrease the risk of perioperative viral transmission to coworkers. An isolated operating room (negative pressure operating room for COVID-19) should be available. It is important to regulate workflow and practices, anesthesia management, health-care, and staff. Cardiac anesthesiologist and health-care workers must be use guidelines to treat patients with COVID-19.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wong J, Goh QY, Tan Z, Lie SA, Tay YC, Ng SY, et al
. Preparing for a COVID-19 pandemic: A review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth 2020;67:732-45.
Joob B, Wiwanitkit V. Variation of 2019 novel coronavirus complete genomes recorded in the 1st
month of outbreak: Implication for mutation. J Res Med Sci 2020;25:33. [Full text]
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al
. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
Munster VJ, Koopmans M, van Doremalen N, van Riel D, de Wit E. A novel coronavirus emerging in China – Key questions for impact assessment. N
Engl J Med 2020;382:692-4.
Engelman DT, Lother S, George I, Funk DJ, Ailawadi G, Atluri P, et al
. Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery. Ann Thorac Surg 2020. pii: S0003-4975(20)30587-7.
Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: What anaesthetists should know. Br J Anaesth 2020;124:497-501.
Zhang HF, Bo L, Lin Y, Li FX, Sun S, Lin HB, et al
. Response of Chinese Anesthesiologists to the COVID-19 Outbreak. Anesthesiology 2020;132:1333-8.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al
. Comorbidity and its impact on 1590 patients with Covid-19 in China: A nationwide analysis. Eur Respir J 2020. pii: 2000547.
Luo M, Cao S, Wei L, Tang R, Hong S, Liu R, et al
. Precautions for intubating patients with COVID-19. Anesthesiology 2020;132:1616-8.
Zhang H, Penninger JM, Li Y, Zhong N, Slutsky AS. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: Molecular mechanisms and potential therapeutic target. Intensive Care Med 2020:1-5. [doi: 10.1007/s00134-020-05985-9].
Ziyaeifard M, Totonchi Z. Real-time ultrasound guided the new standard technique for percutaneous dilatational tracheostomy (PDT). Anesth Pain Med 2015;5:e24653.
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: A case series of 17 patients. Can J Anaesth 2020;67:655-63.