Awake Major Abdominal Surgeries in the COVID-19 Era

Abstract

Background. During the outbreak of coronavirus disease 2019 (COVID-19), allocating intensive care beds to patients needing acute care surgery became a very difficult task. Moreover, since general anesthesia is an aerosol-generating procedure, its use became controversial. This strongly restricted therapeutic strategies. Here, we report a series of undeferrable surgical cases treated with awake surgery under neuraxial anesthesia. Contextual benefits of this approach are deepened. Methods. During the first pandemic surge, thirteen patients (5 men and 8 women) with a mean age of 80 years, needing undelayable surgery due to abdominal emergencies, underwent awake open surgery at our Hospital. Prior to surgery, all patients underwent nasopharyngeal swab tests for COVID-19 diagnosis. In all cases, regional anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain intensities have been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. Postoperative course has been examined. Results. The mean operative time was 87 minutes (minimum 60 minutes; maximum 165 minutes). In one case, conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. No perioperative major complications (Clavien–Dindo ≥3) occurred. Early readmission after surgery never occurred. All nasopharyngeal swabs resulted negative. Conclusions. In our experience, awake laparotomy under regional anesthesia resulted feasible, safe, painless, and, in specific cases, was the only viable option. This approach allowed prevention of the need of postoperative intensive monitoring during the COVID-19 era. In such a peculiar time, we believe it could become part of an ICU-preserving strategy and could limit viral transmission inside theatres.

The comparison of Post-Operative Complications pre Covid era versus during Covid-Era based on Clavien-Dindo-classification: A Systematic Review and Meta-Analysis

“…However, with employment of proper ultrafiltration and protection methods, studies not following this recommendation did not observe such side effect (29,54) Moreover, recent guidelines recommended conservative treatment of uncomplicated appendicitis as a safe option with low failure rate especially in the COVID -19 pandemic (68,69). Prioritization of the patients, ICU preserving techniques, laparotomy with regional instead of general anesthesia (42,45) more extensive use of robotic surgery (70), and distant/home patient monitoring and follow-up were put into test. Despite all limitations, it seems that the means and measures for lowering post-operative complications are effective.…”

Ventral hernia repair under neuraxial anesthesia

“…Over the past several months, the shortage of ICU beds and mechanical ventilation supplies, the limited access to operating rooms (many of them converted into ICUs), and the risk of virus spread have required adaptation of patient management protocols. In some hospitals, several non-deferrable surgical cases could be successfully performed under neuraxial anesthesia without occupation of ICU beds K Ventral hernia repair under neuraxial anesthesia case report [8]. Spinal anesthesia is safe and may represent an effective alternative option to endotracheal intubation in patients who are able to cooperate during the surgical procedure.…”

Anestesia regional como alternativa para procedimentos médicos na pandemia da COVID-19

“…Atualmente, grande parte das cirurgias abdominais são realizadas com técnicas minimamente invasivas (TMI), como cirurgia robótica e laparotomia sob AG. Na pandemia da COVID-19 a funcionalidade e segurança desta prática foi questionada (Romanzi et al, 2020;Romanzi et al, 2021) Romanzi et al (2021 relataram uma treze casos cirúrgicos inadiáveis sob AR (raquianestesia, peridural ou raquianestesia combinada) em pacientes idosos (média de 80 anos), os quais a exposição a AG e fatores relacionados poderiam aumentar as chances de efeitos adversos e morbimortalidade. A intensidade da dor foi monitorada no intra e pós-operatório.…”

“…Apenas em um caso houve a necessidade de conversão para AG e não ocorreram complicações graves perioperatórias e nem necessidade de suporte intensivo pós-operatório. Foi concluído a viabilidade da laparotomia sob AR para cirurgias planejadas, frente a riscos de infecção e a pacientes com comprometimento cardiorespiratório, embora a AG seja frequentemente mais utilizada (Romanzi et al, 2021).…”