Regional Anaesthesia and COVID-19: first choice at last?

Abstract

“In a crisis, be aware of the danger – but recognize the opportunity” John F Kennedy Coronavirus disease 19 (COVID-19) has presented challenges to healthcare systems around the world and will continue to do so for months and perhaps years. The threats that the disease poses to both patients and healthcare workers have changed medical practice, but these changes can offer opportunity to those with subspecialty interests in areas such as regional anaesthesia. Indeed, the European and American Societies of Regional Anaesthesia have produced joint COVID-19 recommendations boldly stating that regional anaesthesia should be preferred over general anaesthesia whenever possible, and practice recommendations for regional anaesthesia during the pandemic have subsequently been published. 1 , 2 The Royal College of Anaesthetists and Association of Anaesthetists also advise using local or regional anaesthesia where practicable and safe in order to preserve key drugs required during the critical care of COVID-19 patients. 3 Other perceived advantages of regional anaesthesia during the COVID-19 pandemic may include: a reduction in aerosol-generating procedures (AGPs) and thereby both increased safety and a saving in the time, resource and financial costs of personal protective equipment (PPE), preservation of immune function when compared with general anaesthesia, improved postoperative analgesia minimising direct contact with care givers, and earlier discharge. However, some of these potential benefits favour healthcare workers and the institution rather than the patients themselves, and we must not forget that patients are at the centre of the shared decision-making process when selecting the safest and most effective anaesthetic technique for a surgical procedure. While the ‘COVID-19 considerations’ listed above are not all patient-centred, resulting changes made to clinical practice may still directly affect the patient. As regional anaesthetists we support the use of regional anaesthesia as the ‘first choice” anaesthetic, but we also believe that the decision to choose regional anaesthesia must remain as patient-centred as possible, minimising risk not only to staff and institution but also to the patient. This is important based upon our collective anecdotal experience whereby the volume of regional anaesthesia practice at all of the authors’ institutions increased considerably during the pandemic. Is regional anaesthesia safer than aerosol-generating procedures? Airway manipulation is associated with some of the highest rates of coronavirus transmission, and it is recognised that minimising AGPs is desirable. 4 Logic suggests that regional anaesthesia reduces the risk of severe acute respiratory syndrome related coronavirus-2 (SARS-CoV-2) transmission from patient to staff, but there are unsurprisingly no randomised controlled trials confirming this. In a recent analysis of the deaths of 106 UK healthcare staff, there were no deaths of staff, including anaesthetists and intensive care doctors, in spite of their working in areas where AGPs were occurring regularly. 5 There are numerous limitations with this study, but one suggestion is that these high-risk groups of staff are knowledgeable and rigorous in their use of PPE. Is it possible that an awake patient anaesthetised with a regional technique, for whom staff are appropriately wearing droplet precaution PPE, poses a greater risk than a well -managed general anaesthetic in a patient who neither coughs on tracheal intubation or extubation nor requires suctioning when staff are wearing AGP PPE? Could some staff be more complacent during non-AGPs such as regional anaesthesia? SARS-CoV-2 is primarily spread via respiratory droplets and fomite transmission. 6 Droplet spread is limited by gravity to <2 m, whereas AGPs lead to more distant spread of the virus which in turn also remains airborne for longer. Coughing and sneezing are considered to be droplet-generating but there is a suggestion that these, or even talking and breathing, may also generate aerosols, which is clearly important in an awake patient for whom droplet precautions alone would be used. 7 Whilst the evidence that SARS-CoV-19 can actually spread in such an airborne fashion remains inconclusive, the results of a retrospective study from China examining a small cohort of anaesthetists providing neuraxial anaesthesia to patients with known COVID-19 were interesting. 8 Subsequent COVID-19 infection was statistically more likely in those anaesthetists who had not worn self-contained breathing apparatus and a fully encapsulating protective suit. Clearly, a causal relationship cannot be established in such an analysis, nor can it be clear whether staff contracted the virus from colleagues rather than patients. PPE use in the UK is stratified into contact, droplet and airborne precautions, and current UK guidance in such elective cases with a low risk of conversion to general anaesthesia remains to wear droplet precaution PPE only. 9 , 10 Outwith the UK, other classifications of PPE have however been suggested, with one such example being: droplet and contact; airborne, droplet and contact; high-risk aerosol-generating medical procedures. 11 Much COVID-19 guidance is based on pragmatism as well as science. 10 For example, two air changes in an operating theatre does not completely eliminate aerosols, rather, this merely reduces the viral load by some 86%. Five air exchanges increase this to nearly 100% but, in theory at least, guaranteed 100% elimination is impossible. Proximity to the patient, duration of exposure and whether the patient actually has COVID-19 as well as the number of air changes are all important considerations in addition to the question of droplet, fomite or aerosol spread. Limiting the period of close proximity between patient and healthcare worker would seem sensible during regional anaesthesia, as would placing a surgical mask on the patient and minimising manipulation of oxygen therapy devices. Interestingly, in contrast to UK guidance, some authors suggest considering the use of airborne precautions during head, neck and upper limb blocks due to proximity to the patient’s airway. 2 Finally, limiting sedation to minimise the risk of coughing would also appear prudent. Other potential advantages of regional anaesthesia Beyond superior analgesia, the evidence for patient, surgical, institutional and environmental benefits provided by regional anaesthesia is growing, with many of these benefits greatest when general anaesthesia can be avoided. 12 , 13 Benefits such as reduced postoperative complications, bypassing or reducing time in recovery, and earlier hospital discharge are particularly valuable. Avoiding a general anaesthetic in patients with active COVID-19 undergoing urgent surgery is likely to be beneficial, but there is also a suggestion that mortality rates of patients with undiagnosed COVID-19 who subsequently undergo surgery is higher. 14 With evidence accumulating that volatile anaesthesia may contribute to decreased perioperative immunity, this is a potentially significant benefit of regional anaesthesia, although such views can only be currently described as speculative. 15 Finally, it may be less daunting for, and slightly easier to communicate with, patients when not wearing AGP PPE. Institutional advantages of regional anaesthesia include avoiding the need for filtering facepiece (FFP) masks, saving both staff discomfort and supplies. Regional anaesthesia may also be useful where negative pressure operating rooms do not exist. Theatre turnover may be improved in non-AGP surgical procedures by avoiding both the post-intubation and post-extubation wait for air changes, and more stringent and lengthy cleaning processes. However, any time saved must clearly be offset against the performance and onset time of regional anaesthesia, although this duration will vary depending both on practitioner expertise and block room availability, which has been shown to increase throughput. 16 Potential issues of regional anaesthesia during the COVID-19 pandemic Consent for regional anaesthesia When consenting patients, anaesthetists must ensure that the patient is aware of the benefits, material risks and any reasonable alternative treatments. 17 In assuming that regional anaesthesia is the safest technique for healthcare providers, we must be careful not to present biased information, and patients must not be denied general anaesthesia. In these circumstances, there is a risk that the consent process becomes healthcare worker rather than patient-centred. One might argue that this is valid on an individual and workforce preservation level, but there may be medicolegal consequences if a patient were to experience a material risk that could have been avoided by an alternative technique that was not offered. Further criticism could be levied if the patient had been assessed, reviewed and consented within the theatre complex immediately before surgery, as has been suggested during the pandemic. 18 While respecting the patient’s right to autonomy, the anaesthetist has the right both to express a preference and to share the view that the healthcare workers in the operating theatre may be safer if the patient undergoes regional anaesthesia. Patient selection It is reasonable to consider administering regional anaesthesia to patients at higher risk of complications simply to avoid a general anaesthesia during the pandemic. In new Association of Anaesthetists guidance on hip fracture, clopidogrel is no longer considered a contraindication to spinal anaesthesia, whilst an acceptable INR is now ≤ 1.5. 19 , 20 These adjustments have been made to facilitate timely surgery, but should they also be considered in a patient with suspected COVID-19? Despite the finding that COVID-19 is associated with hypercoagulability, there is a link between COVID-19 and thrombocytopaenia. 21 , 22 Whilst we are unaware of its detection or severity in asymptomatic COVID-positive patients, a full blood count should be reviewed before performing a neuraxial procedure in anyone with COVID-19, and consideration given to the additional risk of epidural techniques, not just during insertion but also during catheter removal. 23 Where a patient with neurological disease has COVID-19, the risk/benefit pendulum may swing slightly towards regional anaesthesia but, as always, decisions must be made on an individual patient basis taking into account guidance and precautions. 24 Initial reports suggested that as SARS-CoV-2 was not detectable within cerebrospinal fluid (CSF), spinal anaesthesia presented a low risk to patients. However, in light of the publication of a report of the first case of meningitis secondary to SARS-CoV-2 and its isolation within the CSF, this view may need to be re-evaulated. 25 Small case series have suggested that spinal anaesthesia is safe in COVID-19 patients, with no additional haemodynamic or infective consequences. 8 Personal Protective Equipment Some hospitals have suggested (Pawa A, personal communication, 2020) that the “full aseptic technique” be abandoned in a bid to preserve surgical gowns and that only sterile gloves and a mask be donned instead. Whilst not endorsed by the authors, it is recognised that this practice is well established elsewhere even outwith the coronavirus pandemic given the main risk of infection after neuraxial anaesthesia is from respiratory tract pathogens. 26 Regional anaesthesia can also cause conflict over unnecessary PPE utilisation, where some staff still wish to wear FFP3 masks during regional anaesthesia cases due to anxiety about virus transmission. 27 Regional anaesthesia experience and training Key to the delivery of reliable and efficient surgical regional anaesthesia is a capable workforce. Regional Anaesthesia–UK believes that anaesthetists should be able to deliver a small number of high-value or “plan-A blocks” that would be suitable for the majority of cases encountered during the pandemic. 28 One fear is the increased utilisation of regional techniques in which individuals are not well-versed may generate more procedure-specific complications such as pneumothorax or generic complications such as bleeding and nerve damage. One solution is for the most experienced practitioner available to perform the blocks to maximise success, reduce complications, and minimise contact time with the patient, similar to the guidance on airway management in COVID-19 patients. 29 A mobile regional anaesthesia team similar to the COVID intubation team may be one method of delivering such care. Conversely, this could be an excellent opportunity to deliver regional anaesthesia training, not just to trainees missing out on other core modules but also to other colleagues wishing to refresh their practice or upskill. Ultimately, what is most important is that the safest, most effective block for the procedure and patient is performed. Good communication with the surgical team pre-operatively is imperative. A thorough knowledge of the dermatomes, myotomes and osteotomes or visceral structures involved is essential to guide the choice of block, and rescue block if necessary. Meticulous testing before surgery should reduce the need for conversion to general anaesthesia, thereby avoiding issues with upscaling PPE during surgery. Table 1 summarises these and other considerations when performing regional anaesthesia during the COVID-19 pandemic. Table 1 Recommendations for regional anaesthesia for the patient with confirmed or suspected COVID-19. 1 , 2 , 11 , 30 Table 1 Phase of Care Issue Potential Solution Pre-operative Team Brief/Plan • Discuss surgical plan, duration, aerosol generation, appropriate PPE and potential complications with surgical team. Ideally prior to seeing patient. Preoperative assessment • Access electronic health record (EHR) • Virtual pre-assessment via telephone/video call • If virtual pre-assessment/EHR not possible – consider assessment of patient in theatre (preserve PPE) • Check bloods – particular attention to platelet count (thrombocytopaenia) and clotting Pre-existing neurological deficit • Examine for pre-existing neurological deficit and document if present Consent • Discuss material risks and benefits of regional anaesthesia • Provide alternative choices • Frank discussion on reasons for general anaesthesia avoidance • Document discussion Equipment • Don PPE meticulously outside the theatre • Select and prepare appropriate monitoring, equipment. • Only take essential items into theatre • Have a runner available for additional equipment and drugs • Plastic cover/drape on reusable equipment such as ultrasound and nerve stimulator – consider role of hand held devices vs cart-based systems • Plan sedation and airway rescue strategy Transfer to Operating theatre • Patient should be transferred to theatre wearing a surgical facemask. Oxygen mask if required can be placed on top of surgical facemask Intra-operative Technique • Choose most appropriate technique to cover osteotomes, myotomes and dermatomes and tourniquet if required. Account for visceral supply where appropriate in abdominal procedures. • Choose technique with least complications to be sited by most appropriate practitioner (e.g. phrenic nerve sparing upper limb techniques with lowest pneumothorax risk – axillary or infraclavicular brachial plexus blocks, or technique most familiar with) • Use ultrasound to site peripheral nerve blocks (PNBs) ideally • No dose adjustment of local anaesthetics required • Consider adjuvants o To prolong block in PNBs o Ensure suitable post-operative monitoring in place for intrathecal opioids • Consider a mobile “block team” if available Siting of Block • Site block in theatre with essential staff present • Ensure patient wearing surgical mask • Oxygen mask over surgical facemask or nasal cannulae under surgical mask • PPE - Droplet and Contact PPE will suffice for most instances unless concern of conversion to GA or very close contact to patient necessary in which case FFP3 mask may be considered • Ensure Ultrasound probe within sheath prior to scanning Post-block insertion • Allow sufficient time for block to work • Check block meticulously • If in doubt, site supplementary block if appropriate • Continuous monitoring and use of oxygen therapy & sedation if required – avoid high flow oxygen and deep sedation • Have plan for surgical infiltration/rescue if required • Maintain distance of 2 m from patient if possible • Monitor for local anaesthetic systemic toxicity (LAST) • Document record of care Postoperative Recovery • Ideally recover within theatre and transfer patient to final destination wearing surgical face mask as before • Ensure postoperative instructions are documented including monitoring for adverse effects • Prescribe regular postoperative analgesia to commence before block regression and appropriate breakthrough analgesia. Equipment decontamination • Dispose of and decontaminate equipment carefully including ultrasound using appropriate materials (quaternary ammonium chloride disinfectant wipes) • Doff PPE carefully Documentation • Clearly document procedure and outcome – electronically ideally Follow-up • Remote follow up via telephone or electronic health record • Provide contact details • Consider creating an RA database FFP3, filtering face piece 3; PPE, personal protective equipment. Conclusion As regional anaesthesia enthusiasts, we support and encourage the increased use of regional anaesthesia during the pandemic. Despite the additional benefits to healthcare workers and the hospital, the patient must always remain at the centre of the process. These are unprecedented times, and the scales that balance risk and benefit in the perennial regional versus general anaesthesia debate have tipped slightly more towards regional anaesthesia. Well-established regional anaesthesia standards and guidance must still be carefully followed however, and best practice strived for even more so than normal in order to first do no harm. Authors’ contributions Conceptualised, wrote and edited manuscript: all authors. Declarations of interest AJRM is on the Associate Editorial Board of the British Journal of Anaesthesia, an Editor of BJA Education, President-elect of Regional Anaesthesia UK and has received an honorarium from Heron Therapeutics. WHG has no conflicts of interest. AP is President of Regional Anaesthesia UK, has received honoraria from GE and consults for BBraun Medical UK.