These recommendations are based on recent guidelines and protocols followed in major hospitals in India and also from recent articles published online. This cannot be taken as final. Guidelines will be updated from time to time. Watch this presentation in laptop/ pc as slideshow for beautiful animations.

1. PERIOPERATIVE MANAGEMENT OF A
COVID 19 SUSPECT / CONFIRMED
PATIENT
DR. BHAGWATI PRASAD DEWANGAN
CONSULTANT ANAESTHESIOLOGIST
FOPJHRC, RAIGARH

2. INTRODUCTION
Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent
coronavirus, that was first recognized in Wuhan, China, in December 2019.
The World Health Organization (WHO) on March 11 declared COVID-19 a pandemic, and over 200
countries around the world have now been affected by COVID 19.
At this time, there are no specific vaccines or treatments for COVID-19. However, there are many
on-going clinical trials evaluating potential treatments.
Anesthesiologists are at higher risk than healthcare workers of other subspecialties because they
manage the airway and ventilation.
This exposes them to aerosols generated from their airway.
Following recommendations are taken from guidelines followed in major hospitals and from various
sources and cannot be taken as final. New information will be updated from time to time.

3. PRE ANAESTHETIC
CHECKUP

4. IN PAC ROOM
Patients receiving a preanaesthetic checkup should enter the consulting room one by one to minimize
close contact with the clinician and other individuals.
Patients’ body temperatures should be measured (electronic ear thermometer) before entering the
consulting room.
If higher than 37.3°C, he or she must be escorted to fever clinic immediately and should be reported to
the infection control officer on duty of the hospital.
Patients with normal body temperature can proceed with the evaluation at the anesthesia clinic.
Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for
others.
When providing care in close contact with a patient with respiratory symptoms , use face-mask or
goggles, because spraying of secretions may occur.
IN PAC ROOM

5. Cont.
Perform hand hygiene after contact with respiratory secretions.
If possible, use either disposable or dedicated equipment (e.g. stethoscopes, BP cuffs and
thermometers).
If equipment needs to be shared among patients, clean and disinfect between each patient use.
Take a treatment history – patient may be on antimicrobials, anti-retrovirals and hydroxychloroquine etc.
Patient may be on continuous oxygen therapy.
Check the investigations required as per the clinical condition of the patient and the nature of the
surgery.
No elective procedures should be done in such patients.

6. ARRANGEMENT IN PAC ROOM
IDEAL ARRANGEMENT ARRANGEMENT IN CASE OF LACK OF PPE

7. HISTORY
ROUTINE HISTORY
Presence of dry cough
Fever
Shortness of breath
Travel history to high-risk area
Close contact with COVID-19 patients
Occupational exposure
Contact history
Cluster phenomenon
COVID 19 RELATED
Medical history
Surgical history
Anaesthetic exposure in past
Birth history/ obstetrics history
Drug history
h/o Addiction
h/o Allergy
h/o Blood transfusion

8. PHYSICAL EXAMINATION
General examination – check for fever , pulse
and BP for shock
Systemic examination – check for
desaturation, crepitations and wheezing
Local examination/ spine
Airway assessment -- Mouth opening , loose
/missing teeth, adequate neck movement
•

9. INVESTIGATIONS
CBC , CRP and ESR
LFT
RFT and Sr. Electrolytes
PT/INR
Blood sugar
Sr. ferritin and D dimer
CXR and ECG
CT chest
Others ( as required)

10. Signs and symptoms
1. Asymtomatic *
2. Fever
3. Fatigue
4. Dry cough
5. Myalgia
6. Dyspnoea/ shortness of breath
7. Others- diarrhoea and nausea
Imaging
1. CXR – consolidation
2. CT chest – bilateral distribution
of patchy shadows and ground
glass opacity
Lab. Investigations
1. Lymphopenia
2. Leucocytosis
3. Neutrophilia
4. ⬆ LDH
5. ⬆ INR
6. ↑Ferritin
7. ↑CRP and ESR
Complications
1. Shock
2. ARDS
3. Arrhythmia
4. Acute renal failure
Risk factors
1. Male gender
2. Age > 65 years
3. Immunocompromised
4. Diabetic
5. Severe obesity ( BMI> 40 )
6. Severe heart condition
7. CRF undergoing dialysis
8. Chronic lung disease or
asthma
9. Liver disease
CHARACTERISTIC FEATURES OF COVID 19 INFECTION

11. CHANGES SHOWN IN CXR AND CT CHEST

12. IDENTIFY SUSPECTED COVID19 PATIENTS
Although suspected and confirmed case should ideally be identified prior to anaesthetic assessment,
anaesthesiologists should maintain a high index of suspicion, particularly in clinic setting.
If patient is considered high risk, discuss with surgeons on urgency of operation, and delay if possible.
Involve infection control team early in suspected cases.
Consider performing rapid test to confirm diagnosis to guide infection control measures if time allows.
If diagnosis has been established, coordinate with infection control team for isolation purposes.

13. WHEN TO SUSPECT A PATIENT WITH COVID 19
All symptomatic individuals who have undertaken international travel in the last 14 days or
All symptomatic individuals with travel history to COVID 19 hotspot areas of India or
All symptomatic contacts of laboratory confirmed cases or
All symptomatic healthcare personnel (HCP) or
All hospitalized patients with severe acute respiratory illness ( SARI) (fever AND cough and/or shortness of breath) or
Asymptomatic direct and high risk contacts of a confirmed case (should be tested once between day 5 and day 14
after contact)

14. DETERMINE THE LEVEL OF URGENCY
There are different levels of urgency related to patient needs, and judgment is required to discern
between these.
However, if the numbers of COVID-19 patients requiring care escalates over the next few weeks,
the surgical care of patients should be limited to those whose needs are either limb saving or life
saving.
All others including ones requiring postoperative ventilation should be delayed until after the peak
of the pandemic is seen.
Advantages :
•This minimizes risk to both patient and health care team
•Minimizes utilization of necessary resources, such as beds, ventilators, personal protective equipment (PPE), and
unexposed health care providers and patients.

15. RECOMMENDATIONS FOR PRIORTIZATION OF SURGERIES
EMERGENCY SURGERY
Limb or life threatening
⬇
CAN’T POSTPONE
SEMI EMERGENCY
Not immediate life or limb
threatening but may lead to
morbidity and mortality in future
⬇
CONSIDER POSTPONING
NON EMERGENCY SURGERY
Elective and OPD Cases
⬇
POSTPONE THE SURGERY
Examples
1. Obstetrics emergencies
2. Trauma – Neurosurgery
3. Dialysis
4. Limb saving vascular surgery
5. Emergency cardiac procedures
Examples:
1. Cataract
2. TKR or THR
3. Hernia / hydrocele
4. Tympanoplasty
5. Dental procedures
Examples:
1. Elective cardiac interventions
2. Elective ureteric procedures
3. Trauma orthopaedic surgeries
4. Transplant surgeries
Non- life threatening situation:
1. Screening history
2. If positive, postpone till quarantine is over
(14days)/or tested negative
3. Use Full PPE.
4. Cleaning and disinfection with settling time in
between cases of at least 20 min
5. Informed consent to include risks of COVID 19
In life threatening situations:
1. Staff in OT to wear FULL Isolation kit
2. Rapid history for screening
3. Informed consent to include risks of
COVID 19

16. IDENTIFY HIGH RISK PROCEDURES
SURGICAL PROCEDURES
Rigid bronchoscopy
Upper GI Endoscopy
Tracheostomy and
Surgery involving high speed drilling
ANAESTHESIA PROCEDURES
Intubation
Extubation
NIV
Manual ventilation and
Awake fibre-optic intubation

17. ANAESTHETIC GOALS
Regional anaesthesia should be planned wherever possible and GA given only where RA is not possible
or is C/I.
Take explained high risk consent and arrange a bed in the ICU/HDU/ isolation room as indicated.
Ask patient to fill a self declaration form regarding COVID 19 risks.
Communicate pro-actively with patients and families and provide support and prognostic information.
Understand the patient’s values and preferences regarding life sustaining interventions and CPR.
In resource limited settings, where adequate personal protective equipments are not available, it is
imperative to refer the patient to a centre with such facilities.

18. DRUG INTERACTIONS AND SIDE EFFECTS

19. Cont.

20. CARDIOVASCULAR EFFECTS OF ANTI COVID DRUGS
Both chloroquine and hydroxy chloroquine have known safety profiles with the main concerns
being cardiotoxicity (prolonged QT syndrome) with prolonged use in patients with hepatic or
renal dysfunction and immunosuppression but have been reportedly well-tolerated in COVID-
19 patients.
Suggested protocol: ECG at base line
• QTc < 450 ms is normal
• QTc 450- 480ms is borderline
• anything above is abnormal
• Monitoring of QTc on daily basis

21. Cont.
In those who are on anti arrhythmics, ask for cardiology consultation or send ECGs
and drug history and ask for clearance.
In those with history of CAD/ LV dysfunction - will need 2D ECHO before starting these
drugs.
There is no data on other drugs such as Lopinavir or similar medications
Rhythm monitoring will needed in high risk patients
Troponin levels should be done since it has good prognostication factor and also
signals myocarditis

23. Consent
Self declaration form
Routine consent explaining the procedure,
risks and prognosis of surgery.
High risk consent for post op icu and
ventilator requirement.
Ask to sign a Self declaration form
regarding COVID 19 risks.

24. PREOPERATIVE
MANAGEMENT

25. OPTIMIZE PATIENTS CONFIRMED WITH COVID-19
Assess airway meticulously and formulate airway plan.
Determine severity of respiratory compromise.
Note oxygen requirements, chest x-ray changes and arterial blood gas.
Look for organ failure, particularly signs of shock,liver failure,renal failure etc.
Review current antivirals to avoid drug interactions with anaesthetic medications.
Determine post-operative disposition of the patient, including the need for intensive
care support.

26. OT PREPARATION
All OTs should be labelled as COVID -19 OTs with a large bill board.
The OT should have negative pressure ventilation.
Air conditioning and any positive pressure ventilation should be turned off.
Laminar flow and the functional high-efficiency filters are preferable.
Minimise the number of people in the OT.
All likely to be used drugs and equipments should be kept ready in a separate tray and
prepared beforehand.
OT PREPARATION

27. Cont.
All areas where patients with SARI are cared for should be equipped with :
1. Pulse oximeters
2. Functioning oxygen systems and
3. Disposable, single-use, oxygen-delivering interfaces (nasal cannula, simple face
mask, and mask with reservoir bag).
Remove all unnecessary equipment from OT.
Can keep crash cart, defibrillator, airway trolley and drug trolley in corridor outside the
OT.

29. Cont.
Vasopressors must be prepared and kept ready.
Apply 2 high quality HME filters –one between the ETT and anaesthesia circuit
and the other between the expiratory limb of the circuit and anaesthesia machine.
Place a high quality viral filter (can use the epidural catheter filter 0.2 microns)
between the CO2 sampling line and the water trap.
PPE for all theatre staff must be available and properly donned once OT is checked
and prepared.
Monitors can be covered with plastic sheet/cling film.

30. PATIENT TRANSFER TO OT
Apply lowest oxygen flow possible to maintain oxygenation to minimise aerosol-
generation.
Depending on the individual risk assessment, if a patient requires high oxygen
administration, PPE may be appropriate.
Consider early intubation, if patient requires high-flow oxygen for transport.
Give suspect patient a triple layer surgical mask/N95 mask and shift patient to separate
room if available or otherwise wheel directly into the OT.
Do not keep in the preoperative area.
Maintain a distance of at least 1-2 m from the patient while taking history especially if
patient is coughing or sneezing.
PATIENT TRANSFER TO OT

31. Cont.
Keep at least 2 meter distance between suspected patients and other
patients.
Route from ward to operating theatre should be planned ahead to
minimise patient contact with others.
In the operation theatre area, avoid transporting patient via a common
control or recovery area.
If that is not possible, other patients should be partitioned off from the
path of the infected patient.

32. INTRA OPERATIVE
MANAGEMENT

33. GENERAL ANAESTHESIA
BEFORE INDUCTION
Reiterate infectious risk of the patient and the level of precautions required to all members in the
theatre.
Communicate clearly with anaesthetic nurse or assistant on airway plan as talking and hearing
through N95 respirators and face shields could be difficult.
Consider disposable covers for surfaces to reduce droplet and contact contamination.
Most experienced anaesthesia personnel should intubate.
Wear PPE.
GENERAL ANAESTHESIA

34. Cont.
Use double gloves.
Prefer the use of video laryngoscope (disposable).
Preload the ETT over a stylet or bougie to increase the chances of successful intubation
especially while using video laryngoscope.
Use a ‘gauze’ wipe technique while removal of stylet to prevent aerolisation.
Ensure adequate neuromuscular blockade to avoid coughing and bucking that leads to
aerosol generation.
IV lignocaine 1.5 mg/kg before intubation/ extubation to avoid coughing.

35. Cont.
Give fentanyl slowly, in small aliquots if required to reduce coughing
Use rapid sequence induction to reduce the need for mask-ventilation.
Remove outer glove and wrap the laryngoscope blade after intubation in it.
Immediately inflate the cuff of the ETT after intubation.
Chest auscultation after intubation is not recommended - instead rely on
capnography, chest movement and SpO2.

36. Cont.
If desaturation occurs during apnea period of RSI, can do manual ventilation
with small tidal volume breaths.
At this time use a two - handed mask holding technique in order to ensure the
best possible mask seal.
If first attempt at intubation is not successful do not reattempt intubation.
Use a 2nd generation disposable intubating supraglottic device (LMA Supreme,
Proseal LMA or I-GEL).
Closed suction catheter for endotracheal suction if required. No open tracheal
suction to be done.

37. SUPRAGLOTTIC AIRWAY DEVICE CLOSED SUCTION CATHETER

39. USE PPE WHILE INTUBATING THE PATIENT

40. USE OF VIDEOLARYNGOSCOPE INCREASES THE DISTANCE BETWEEN THE PATIENT
AND THE ANAESTHESIOLOGIST

41. AEROSOL BOX TO MINIMISE EXPOSURE TO AEROSOLS DURING
INTUBATION

42. IF PPE OR AEROSOL BOX IS NOT AVAILABLE , WE CAN USE TRANSPARENT C-ARM
COVER TO PREVENT DIRECT EXPOSURE TO AEROSOLS AND SECRETIONS.

43. AVOID FOLLOWING PROCEDURES THAT MAY LEAD
TO AEROSOLIZATION
High flow nasal cannula @ more than 6L/min.
Awake fiberoptic intubation.
Entonox /Inhalation sedation.
NIV
Bag mask ventilation, use of T- piece.
Open suction.

44. MAINTENANCE
Circuit- Use disposable closed circuits with low gas flows.
Limit any circuit disconnection; if disconnection is required, do at the end of expiration
only and clamp the ETT at that time.
Place the ventilator on standby whenever a circuit disconnection is required, such as tube
repositioning.
Restart mechanical ventilation only after the circuit has been reconnected/ closed.
Mechanical Ventilation –
• TV – 4-8 ml/kg
• Plateau pressure < 30 cm H20
• Permissive hypercapnia with goal of ph being 7.3 – 7.45.

45. Cont.
Use prophylactic antiemetics to prevent PONV.
Analgesia- use opioids or paracetamol. Avoid NSAIDS.
Fluids- Avoid excessive fluid therapy in ARDS. Use isotonic crystalloids. Avoid colloids.
Vasopressors- Use Noradrenaline as vasopressor of choice if MAP ≤ 65 mm Hg & S.Lactate >
2mmol/l in absence of hypovolemia.
Add Vasopressin or Adrenaline - in addition to Noradrenaline if required. Avoid Dopamine.
Use Dobutamine in case of cardiac insufficiency.

46. EXTUBATION
During tracheal extubation cover the patient’s head with plastic sheath or plastic box.
Extubation should avoid aerosolization so consider deep extubation in spontaneously breathing
patient to reduce coughing.
LMA exchange using a closed circuit can also be used.
Keep confirmed patient in isolation operating theatre for post-anaesthetic care.
Arrange case handover with the receiving team in the operating theatre.
Strict adherence to proper doffing at designated location and perform hand hygiene

47. REGIONAL ANAESTHESIA
Theoretical risk of seeding infection into the central nervous system in viraemic patients.
No evidence in support.
Spinal anaesthesia and epidural blood patches have been performed in obstetric patients with
HIV without any seeding.
Although the risk of CNS infection is plausible, it should be balanced against the risk of
performing general anaesthesia on patients with COVID-19.
Use a pencil-point spinal needle for spinal anaesthesia.
It may reduce the risk of introducing viral material into the CNS, as there is less tissue coring
compared with cutting tip spinal needles.
REGIONAL ANAESTHESIA

48. MODIFICATIONS IN REGIONAL PROCEDURES
Patient must wear N95 or triple layer surgical mask throughout the procedure.
If O2 is required, an O2 mask may be placed over the above masks.
If patient has lots of secretions, consider covering nose and mouth with 2 layers of wet gauze
pieces.
There is a higher incidence of hypotension in these cases, so vasopressors- preferably
Noradrenaline should be kept ready.
Consider early use of vasopressors (Noradrenaline).
Fluid preloading should be done judiciously to prevent pulmonary oedema.

49. Cont.
CSE may be preferred over SAB to prevent need for GA.
Still there is always a possibility of converting to general anaesthesia should
regional anaesthesia fails, so take adequate precautions.
Airborne precautions are necessary if the patient requires high flow oxygen.
Full-length sheaths/covers for ultrasound probes to minimise contamination.
Hand hygiene before and after procedure.

50. OBSTETRICS ANAESTHESIA
Consider early epidural analgesia to minimise need for general ananesthesia in case of
emergency caesarean section.
Consider regional anaesthesia unless contraindicated.
Temporarily separate the mother from her baby after delivery while diagnostic testing is
being performed.
Although there is currently no evidence to suggest vertical transmission taking place,
transmission after birth via contact with infectious respiratory secretions is possible.
Involve paediatricians early for caring for neonates born to COVID-19 mothers.
Meanwhile insure contact PPE (gown, gloves, facemask and eye protection) for feeding and
care.
OBSTETRICS ANAESTHESIA

51. MODIFICATIONS IN CPR
CPR involves a series of events that increase the risk of aerosol
generation, including suctioning, mask ventilation and intubation.
Never give mouth to mouth breathing in these patients.
Consider apnoeic oxygenation instead of providing breaths via bag
valve mask to maintain airway patency and ventilation.
Intubate early in a resuscitation to secure and isolate the airway
and possible aerosol generation.
Hold chest compressions temporarily during intubation to reduce
the risk of inhaling infective aerosols by the intubating clinician.

52. Cont.
LUCAS MANUAL COMPRESSOR
Consider utilising chest compression
system LUCAS to deliver automated
compressions if available.
This reduces the number of
healthcare workers required in close
proximity to the patient.

53. DURING CPR SIMPLY COVER THE PATIENT WITH C ARM COVER SO THAT HEALTH CARE
PROVIDERS ARE PREVENTED FROM DIRECT EXPOSURE FROM AEROSOL AND
SECRETIONS

54. POST OPERATIVE
MANAGEMENT

55. CLEANING OF OT
All unused items on the drug tray and airway trolley should be assumed to be contaminated
and discarded.
Discard breathing circuit, mask, tracheal tube, HME filters, gas sampling line and soda lime after
every patient.
Water trap to be changed if it becomes potentially contaminated.
Seal all used airway equipment in a double zip-locked plastic bag.
It must then be removed for decontamination and disinfection.
After removing protective equipment, avoid touching your hair or face before washing hands.

56. Cont.
All staff has to take shower before resuming their regular duties.
A minimum of one hour is planned between cases to
• Allow OT staff to send the patient back to the ward
• Conduct thorough decontamination of all surfaces, screens, keyboard, cables, monitors
and anaesthesia machine with 2 to 3% hydrogen peroxide spray disinfection, 2-5 g/l
chlorine disinfectant, or 75% alcohol wiping of solid surfaces of the equipment and
floor.
The hydrogen peroxide vaporizer is an added precaution to
decontaminate the OT.

57. Facility for full body sanitization before and after duty of health care
provider

58. POSTOPERATIVE PATIENT CARE
To minimise transmission from the patient to health-care workers and other patients, employ the
following measures.
1. Avoid transferring confirmed cases to the post-anaesthetic care unit.
2. Clean and disinfect high-touch surfaces on the anaesthesia machine and anaesthesia work area with an
Environmental Protection Agency (EPA)-approved hospital disinfectant.
3. Allow time for aerosols in isolation to be washed out, the time required depends on the air changes
per hour of the specific location. ( Atleast 20 mins.)
4. Consider applying a surgical mask to all other awake and stable patients in the recovery area.
5. In the recovery room, distance between patient beds should be at least 1-2 m.
6. Avoid giving high flow oxygen, NIV, or nebulised medications.

60. ARRANGEMENT FOR SAMPLE COLLECTION

61. PROGNOSIS
There was a retrospective study done by Shaoqing Lei et al in March 2020 in Wuhan of 34 patients who
underwent elective surgeries during the incubation period of COVID 19 .
All the patients developed COVID 19 pneumonia shortly after surgery with abnormal findings in CT scans.
Of the 34 patients , 15 ( 44.1%) required ICU care and 7 ( 20.5%) patients died after admission to ICU.
The most common complications in non survivors were – ARDS, shock, arrhythmia and acute cardiac injury.
** compared to non icu patients, icu patients were older, underwent more difficult surgeries, were more likely to
have underlying comorbidities and had abnormal laboratory investigations.
In this study they derived that surgery may accelerate and exacerbate disease progression of COVID 19.
This was derived from the finding that median time of COVID 19 onset to dyspnoea in current study was 3.5 days
which is shorter than reported time of two other studies of confirmed SARS- COV -2 positive cases in wuhan.

62. BUT TAKE CARE OF YOURSELF ALSO !!!!
If healthcare workers who had direct contact with confirmed or suspected
patients develop fever, cough or fatigue, they must inform the occupational
health department of the hospital.
Complete blood tests including C-reactive protein and CT chest should be
performed.
If a healthcare worker meets the criteria for medical observation, he or she
should be self-isolated at home.

63. TAKE HOME POINTS
The COVID-19 is a highly contagious disease, posing a huge burden to the health care
system.
In providing optimal perioperative care to patients, it is also our duty to protect health
care workers and other patients from contracting the disease.
But firstly, we have to protect ourself both medically as well as medicolegally from some
sections of society who blame medicos for everything that goes wrong with them.
With careful planning and execution of infection control measures, disease transmission
can be minimised.

64. THANK YOU