Anesthesia for Patients Undergoing Anesthesia for Elective Thoracic Surgery During the COVID-19 Pandemic: A Consensus Statement From the Israeli Society of Anesthesiologists

Abstract

Anesthesia for thoracic surgery requires specialist intervention to provide adequate operating conditions and one-lung ventilation. The pandemic caused by severe acute respiratory syndromeÀassociated coronavirus 2 (SARS-CoV-2) is transmitted by aerosol and droplet spread. Because of its virulence, there is a risk of transmission to healthcare workers if appropriate preventive measures are not taken. Coronavirus disease 2019 (COVID-19) patients may show no clinical signs at the early stages of the disease or even remain asymptomatic for the whole course of the disease. Despite the lack of symptoms, they may be able to transfer the virus. Unfortunately, during current COVID-19 testing procedures, about 30% of tests are associated with a false-negative result. For these reasons, standard practice is to assume all patients are COVID-19 positive regardless of swab results. Here, the authors present the recommendations produced by the Israeli Society of Anesthesiologists for use in thoracic anesthesia for elective surgery during the COVID-19 pandemic for both the general population and COVID-19Àconfirmed patients. The objective of these recommendations is to make changes to some routine techniques in thoracic anesthesia to augment patients' and the medical staff's safety.

Anesthetic Management for Thoracic Surgery During the COVID-19 Pandemic

“…The most widely used device for enabling lung isolation is a double lumen tube (DLT). Most published literature regarding lung isolation during the pandemic focuses on recommendations for DLT use [ 25 •, 27 , 29 – 31 ]. Other options include bronchial blockers and, rarely, single lumen tubes advanced into the bronchus of the non-operative lung.…”

“…Airway manipulation and device exchange in critically hypoxic patients can be poorly tolerated, and the risk of aerosol generation is increased during this time. As before the pandemic, intubation with a single lumen tube and use of a bronchial blocker may also be a better option for patients with predicted difficult airways or those requiring awake fibre optic intubation [ 26 •, 27 , 29 ].…”

“…There is conflicting advice among societies regarding the use of bronchoscopy in this context. Regarding DLT placement, some societies advocate clinical confirmation of DLT position suggesting that bronchoscopy should be reserved for encountering difficulty or troubleshooting tube misplacement [ 27 , 28 ], whereas the majority still advocates the use of bronchoscopy in all patients [ 25 •, 26 •, 29 , 31 , 36 ], as it is the most reliable method of device placement. Guidelines concur that it should only be performed; during gas flow cessation, patient apnoea, without positive pressure in the circuit, and the adjustable pressure-limiting (APL) valve set at zero cmH 2 O.…”

“…The bronchoscope should be kept in a designated area and ideally used by a single operator with appropriate hygiene steps following each use [ 25 •]. Disposable single-use bronchoscopes are also recommended if available [ 27 , 29 ]. Other described adaptations to reduce aerosol generation during bronchoscopy include the use of a clear sterile laparoscopic camera cord cover that acts as a closed barrier sheath by enclosing the bronchoscope proximally and distally at the airway device connection [ 37 ].…”

EACTA/SCA Recommendations for the Cardiac Anesthesia Management of Patients With Suspected or Confirmed COVID-19 Infection: An Expert Consensus From the European Association of Cardiothoracic Anesthesiology and Society of Cardiovascular Anesthesiologists With Endorsement From the Chinese Society of Cardiothoracic and Vascular Anesthesiology

“…There are several published consensus statements ( 4 ) ( 5 ) ( 6 ) and joint recommendations on the perioperative management of COVID-19 patients during different varieties of surgery ( 7 ) ( 8 ) EACTA and SCA believe that is important to develop this joint-consensus for the perioperative management of patients undergoing cardiac surgery and minimally invasive cardiac interventions during the COVID-19 pandemic, based on the best evidence available until now. First, this consensus could serve as a guide to cardiac anesthesiologists in light of continuing cardiovascular care delivery services during the evolving second and perhaps subsequent waves of COVID-19.…”