COVID-19

Pediatric Regional Anesthesia During COVID-19

By Harshad G. Gurnaney, MBBS, MPH; Wallis T. Muhly, MD
Department of Anesthesiology and Critical Care Medicine
Children's Hospital of Philadelphia
Perelman School of Medicine
University of Pennsylvania

Background
The coronavirus disease pandemic (COVID-19) has rapidly spread across all continents and it has had significant impacts on healthcare systems, and how healthcare is delivered.  The causative virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is transmitted via contact, droplet, and aerosol-based routes making healthcare workers particularly vulnerable.  In the conduct of routine anesthetic care, performing aerosol generating procedures (AGPs) such as intubation, deep suctioning and extubation, can expose anesthesia personnel, operating room and recovery room healthcare providers to aerosolized virus which may increase the risk of contracting and transmitting SARS-CoV-2.

While the pediatric burden of COVID-19 is low, pediatric practitioners may encounter patients with SARS-CoV-2 who require surgical procedures. Regional anesthesia has been suggested as a safer alternative to general anesthesia during this pandemic as it limits the need to perform AGPs.1  However, when caring for children, most regional anesthesia is performed with the patient under general anesthesia. In some select patient populations (e.g. adolescents requiring extremity procedures), regional anesthesia can be used as the sole anesthetic, and this approach may be a reasonable option to discuss with the patients and parents. Although general anesthesia may be the better option for pediatric patients, the use of regional anesthesia should still be considered as it provides benefits during the postoperative period, including reduced opioid use, better pain control, and a reduced incidence of nausea/vomiting.

Perioperative Care
Patients coming for elective or emergency procedures should be screened for SARS-CoV-2 to allow practitioners to plan for their perioperative care based on these results.

  • SARS-CoV-2 negative or non-PUI patients:

For patients with negative results and are determined to not be a patient under investigation (PUI) (e.g. no residence in endemic areas, exposure to a person with SARS-CoV-2 infection), care should proceed as per institutional guidelines for infection prevention as done before the pandemic.

  • SARS-CoV-2 positive or PUI patients:

Preoperative Preparation
A detailed history and physical exam should be performed to identify relevant patient comorbidities and anesthetic risk factors.  As thrombocytopenia has been reported in patients with severe COVID-19 disease, it is advisable to check a platelet count before neuraxial procedures in these patients. For a patient with post-dural puncture headache who needs an epidural blood patch, there is concern about injecting viremic blood into the epidural space, especially during an active illness. It may be preferable to postpone the blood patch until recovery from the acute infection.  Assent and consent for general and regional anesthesia should be obtained from the patient (when appropriate) and legal guardian following a thorough explanation of the risks and benefits of proceeding with anesthesia.  

Only the essential equipment and drugs for the procedure should be prepared and brought into the operating room. When possible, single-use equipment should be used for these procedures. All back-up equipment and emergency drugs should be accessible just outside the operating room with an identified provider available to transfer them into the operating room.2

Procedures for protecting and cleaning ultrasound equipment should be in accordance with institutional infection prevention policy. Some institutions are using a single-use plastic cover to protect the controls and the screen of the ultrasound machine. A single ultrasound probe should be selected for the procedure brought into the operating room.

Intraoperative Management
All awake or sedated pediatric patients should have surgical masks on during the procedure. If supplemental oxygen is required, it can be delivered using a face mask or a nasal cannula under a surgical mask at the lowest flow rate required to maintain oxygen saturation. Oxygen supplementation using a venturi mask, non-invasive positive pressure ventilation, and high-flow nasal cannula are considered to increase the risk of SARS-CoV-2 aerosolization. It is recommended to perform these procedures in an operating room to avoid contamination of common areas (preoperative room or block room).

As both neuraxial and peripheral nerve blocks are not considered AGPs, healthcare providers performing these on patients should use contact and droplet precautions (surgical mask, eye protection, and double gloves). If a patient is intubated, continue to use appropriate precautions to prevent contamination of the anesthesia machine and avoid disconnecting the anesthesia circuit for patient repositioning when possible.

Currently, no dose adjustment for spinal, epidural, or peripheral nerve blocks in COVID-19 patients is recommended. When choosing between different peripheral nerve blocks, preference should be given to peripheral nerve blocks that preserve respiratory function (infraclavicular block over interscalene block) as the respiratory status may already be compromised in COVID-19 patients. The use of peripheral nerve block catheters needs to be made on a case-by-case basis, weighing the benefits of opioid reduction to the additional resources needed to place and maintain these catheters, which may include additional patient contact to assess the catheter site and neurologic function.

Postoperative Care
The patient should be monitored in the operating room until they can safely be transferred to a designated COVID-19 area of the hospital. The risk of transmission for SARS-CoV-2 is high during the doffing of personal protective equipment (PPE). Extra time should be allowed for donning and doffing PPE in designated areas of the hospital. The presence of an observer and/or cross monitoring between providers is recommended during the donning and doffing of PPE. Simulation sessions should be conducted for training staff in donning and doffing of PPE. Any reusable equipment utilized during the procedure should be disinfected as per institutional guidelines. All single-use equipment and drugs should be discarded as per institutional guidelines.

References

  1. Ashokka B, Chakraborty A, Subramanian BJ, Karmakar MK, Chan V. Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective. Reg Anesth Pain Med 2020 May 28; Online ahead of print.
  2. Lie SA, Wong SW, Wong LT, Wong TGL, Chong SY. Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic. Can J Anaesth 2020; 67: 885-92.
  3. https://www.asra.com/page/2905/practice-recommendations-on-neuraxial-anesthesia-and-peripheral-nerve-blocks-dur

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